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

Diagnosis: Central Nervous System/ Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied increase in PCA services to 7 days a week 8 hours per day.  
The health plan's determination is overturned in whole.

The patient is a male with past medical history of dementia, hypertension, coronary artery disease, chronic low back pain, glaucoma, cataracts, peripheral vascular disease, urinary incontinence, cerebral vascular disease, benign prostatic hyperplasia (BPH), osteoarthritis, and vertigo who had been assigned personal care assistance (PCA) services 3 hours/day, 7 days/week, to total 21 hours/week based on assessment tool performed over the telephone. At the telephonic assessment the patient was assessed at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, transportation, and equipment management. The patient was assessed at limited assistance with tasks of phone use, stairs and bathing while supervision only with locomotion and transfer toilet. The patient was assessed as independent with tasks of personal hygiene, dressing upper/lower body, walking, toilet use, bed mobility, and eating.

The subject under review is the medical necessity for the increase in personal care worker (PCW) services to 7 days per week 8 hours per day for this patient.

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

The patient has diagnosis of dementia and osteoarthritis which are progressive debilitating illnesses. The patient's primary care physician (PCP) documents the patient's past medical history and limitations with successfully completing ADLs and Instrumental activities of daily living (IADLs) without assistance. The PCP specifically notes the patient is not able to independently cook, clean, bath, dress, grocery shop and maintain household as well as needing prompting with eating meals and taking medication three times a day. Both of the assessment tools were performed via telephone and underestimated the patient's assistance level with tasks of personal hygiene, dressing upper/lower body, walking, locomotion, toilet use, bed mobility, and eating. The patient has unscheduled and unpredictable care needs over a continuum of time and the plan does not assure that the plan of care developed can meet these unscheduled or recurring daytime needs that the patient needs assistance with. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Ears/Nose/Throat. 
Treatment:  Surgical Services - Eustachian Tube Dilation
The insurer denied the Eustachian Tube Dilation. 
The denial is upheld in whole.

The patient is a male who was seen for complaints of a bubbling, clogged sensation in his ears bilaterally.  Audiogram showed bilateral sensorineural hearing loss with type A tympanogram bilaterally (normal).  A computed tomography (CT) scan of the temporal bone showed normal middle ears and mastoid aeration bilaterally.

Per the provided case notes the patient also complained that his symptoms increase with higher altitudes and were improved with tympanostomy tubes that were placed.  The patient was seen again and the patient stated there was no improvement with topical nasal steroid use.  The provider recommends Eustachian tube dilation for Eustachian tube dysfunction (ETD).

The subject under review is whether this is likely to be more beneficial for this patient than any standard treatment.

The health plan's determination is upheld in whole.

There is no strong evidence that the proposed treatment (bilateral Eustachian tube dilation) is likely to be more beneficial then any standard treatments for this patient.

From a clinical standpoint, there are no objective findings in this patient to support a diagnosis of ETD.  The patient had normal tympanograms, no conductive hearing loss and a CT which showed no signs of chronic middle ear disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Ears/Nose/Throat. 
Treatment:  Surgical Services - Eustachian Tube Dilation

The insurer denied the Eustachian Tube Dilation.  The denial is upheld in whole.

The patient is a male who complained of "bubbling" in his ears that feel clogged and full, with "wetness in the inner ear" for the past 3 years.  He has undergone myringotomies with ventilating tubes, and this helps until the tubes extrude.  Exam of the ears was normal.  An audiogram revealed a mild to moderate sensorineural hearing loss with a word recognition of 84% bilaterally, and normal tympanograms.  He was treated with Flonase nasal spray with no improvement in symptoms.  Computed tomography (CT) of the temporal bones showed a right mildly prominent vestibular aqueduct, and a suggestion of a left semicircular canal dehiscence.  Balloon eustachian tube dilation was recommended and is the service under review.

The health plan's determination is upheld in whole.

The proposed treatment, balloon eustachian tube dilation is not likely to be more beneficial than any standard treatment or treatments for eustachian tube dysfunction.

Micucci et al, in a review of the literature, concluded that eustachian tube balloon dilation is a novel technique for the treatment of chronic eustachian tube dysfunction and its role continues to evolve and develop.  Current practice patterns demonstrate wide variability in the assessment of eustachian tube dysfunction, heterogeneity in the timing of dilations and controversy in preoperative CT screening.  Gurtler et al concluded in a study of a cohort of 2 that the pathophysiologic mechanism of eustachian tube balloon dilation remains unclear and long-term analysis and stratification of patients are needed to better evaluate the definite value of eustachian tube balloon dilation.  Hwang et al performed a systematic literature review on nine prospective studies, describing 713 patients who were treated with balloon eustachian tube dilations, and pooled data analysis and qualitative analysis were conducted.  It was concluded that further investigations were warranted to establish a higher level of evidence of efficacy for dilation of the eustachian tube.

Based upon the evidence-based literature, the proposed service, balloon eustachian tube dilation for dysfunction of the eustachian tubes, is not likely to be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male. He presented to the emergency room with weakness, polyuria, and polydipsia. His glucose was 231 mg/dL, bicarbonate 29, and A1C (glycated hemoglobin) 13.5%. He was treated with intravenous fluids, glipizide, and metformin. Endocrinology was consulted. 

This patient presented with hyperglycemia and new diagnosis of diabetes. The documentation does not support that he was hemodynamically unstable. He did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome.  In addition, diabetes education can be provided under observation status or as an outpatient. Therefore, no, the proposed inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Perirectal abscess

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed.   

This is a male patient with a medical history of type 2 diabetes mellitus and hemorrhoids. He presented to the Emergency Department (ED) with complaints of rectal pain and bleeding for the past two weeks. His presenting vital signs were; blood pressure 157/78, heat rate 131, and a respiratory rate 18. He reported that he had been treated at an urgent care center with steroid rectal suppositories and stool softener with no relief. The patient stated that he had intermittent colicky pain with episodes of 11 out of 10 pain rating. On physical examinations it was reported that he had an external non-thrombosed hemorrhoid; the exam was limited due to patient's inability to tolerate further examination due to his pain. He was admitted to the hospital for further treatment for pain management and examination of his rectal hemorrhoid. He went to the Operating Room for a rectal examination under general anesthesia revealing a rectal abscess. An incision and drain (I&D) was performed draining approximately 30 cc of purulent material. The patient experienced no post procedure complications. He was consulted by Endocrinology for his uncontrolled diabetes; he had HgA1c of 11.2%. He was started on insulin and was counseled on his adherence to a diabetic diet. The patient was medically stabilized and discharged home. 

According to MCG Health Inpatient and Surgical Care 23rd Edition Cellulitis ORG: M-70 (ISC) Clinical Indications for Admission to Inpatient Care: Admission is indicated for patients who has high-risk comorbid condition, such as poorly controlled diabetes (HgA1c greater than 10%) and/or have severe pain requiring acute inpatient management. This patient's poorly controlled diabetes with HgA1c of 11.2% and severe pain refractory to outpatient care at the urgent center meets this MCG guideline recommendation for inpatient admission. According to MCG Health General Recovery Care 23rd Edition on Wound and skin management GRG: PG-WS (ISC GRG), continued inpatient stay is recommended for patients who needed inpatient interventions. This patient was noted to have need inpatient intervention for his diabetes control and management.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of this patient in denying this inpatient admission as the patient had uncontrolled diabetes in the setting of an abscess. 

The carrier's denial of coverage for the acute inpatient hospital services is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Odontogenic infection.
Treatment:  Inpatient admission.

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

This patient is a female child with a history of dental caries, who presented to the Emergency Room (ER) with complaints of pain and swelling of the right side of her face over the mandible area for 2 days, following pain to a right lower molar tooth for about 1 week.  It is noted in the history of present illness (HPI) that she had decreased appetite because of the pain but could still chew, eat and drink.  There was no difficulty in swallowing or breathing.  She had a fever at home.  There was a cavity noted on a past dental examination, and the dentist at the time recommended a filling, but the patient's mother was unable to follow up.

On examination by oral maxilla-facial surgeon (OMFS) and the emergency department (ED), there was mild lower right mandibular swelling, tenderness to palpation in the right masseter area, with no fluctuation, and the lower inferior border of the mandible was palpable.  There was moderate swelling noted on right lower buccal mucosa and right lower gum, mostly around the second molar.  There was gross decay on several primary teeth with no visibly draining purulence.  A cavity was noted on the second molar, and an approximately 1.5 centimeter right cervical mobile lymph node.  The patient had cellulitis overlying a clinically diagnosed deep-seated dental or buccal space infection that could be a dental abscess, and was recommended to be treated for this per the OMFS dental consult with 2 doses of intravenous (IV) antibiotics and discharge home on oral antibiotic following that, with follow up for dental evaluation. 

Odontogenic infections are usually confined to the alveolar ridge vicinity, usually as a periapical infection, and complications are uncommon.  The most important treatment modality in such an odontogenic infection is the elimination of the primary source of the infection by surgical drainage, with antibiotics as adjunctive therapy, which was not recommended to be done immediately by the OMFS dentists.  Moreover, as the patient's vital signs were stable and her oral intake was only slightly diminished, admission to the hospital was unnecessary solely for the administration of 2 doses of IV antibiotics. 

The medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding
Treatment: Inpatient Hospital Admission

The insurer denied coverage for the Inpatient Hospital Admission.
The denial is upheld. 

This is a male patient with a past medical history of Crohn's disease, anal fistula, ischiorectal abscess, proctitis, gastritis, anemia, and pisiform tendon rupture. The patient presented to the Emergency Department (ED) due to subjective complaints of rectal bleeding with constipation. The patient reported that on the morning of presentation to the ED, he felt like he was unable to have a bowel movement. The patient reported that he strained on the toilet for approximately 45 minutes before passing a small amount of stool with blood. The patient reported regular small amounts of bleeding, but the volume was larger than usual. The patient called his gastroenterologist who told him to go to the ED. The patient had no history of constipation. The patient felt like he needed to go, but was unable to, and when he tried, the patient just passed blood.  The patient reported fullness in his abdomen.  

The patient's physical examination revealed the abdomen was soft; there was no rebound tenderness or guarding. There was some abdominal fullness over the descending colon. There were external hemorrhoids that were non-inflamed. The internal examination showed some stool in the rectum, but no impaction. In the ED, the patient had worsening rectal bleeding. The patient was to be admitted to medicine with a diagnosis of rectal bleeding. The patient's gastroenterologist was to perform a colonoscopy. The patient also had left calf pain that was likely from pisiform tendon rupture which was being treated conservatively. The patient's left lower extremity ultrasound revealed no evidence of deep vein thrombosis (DVT). The patient's computed tomography (CT) scan of the lower abdomen revealed findings consistent with Crohn's proctitis. The patient was stabilized and on day 2 of admission, the patient was discharged.

Milliman Care Guidelines (MCG) guidelines for inflammatory bowel disease (M-565), recommends inpatient admission when there is evidence of acute severe ulcerative colitis as indicated by 6 or more bloody bowel movements per day as well as evidence of systemic illness as indicated by a pulse greater than 90 beats per minute, or temperature greater than 100 degrees, or hemoglobin less than 10.5, or erythrocyte sedimentation rate (ESR) greater than 30, or C-reactive protein greater than 30. In this case, the patient did not have six or more bloody bowel movements per day and there was no fever in the ER to warrant inpatient admission. The patient's hemoglobin was 13.8, and the patient was hemodynamically stable. As such, the Inpatient Hospital Admission is not considered medically necessary for this patient.

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

The carrier's denial of coverage for the Inpatient Hospital Admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anaphylaxis including diaphoresis and generalized hive.
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of seizure, bipolar disorder, and alcohol use.  The request is for evaluation of medical necessity for inpatient admission.  

No, the proposed inpatient admission was not medically necessary.

The patient presented with acute symptoms of anaphylaxis including diaphoresis and generalized hive.  The patient's vitals upon presentation to the emergency room showed tachycardia and high blood pressure.  The patient has received intravenous epinephrine, intravenous antihistamines and corticosteroids.  The patient has responded well to the above treatments.  

According to the clinical flow sheet, the patient was clinically stable with no acute complaints such as systemic symptoms of trouble breathing, swollen tongue or mental instability at the time of admission.  His blood pressure was recorded to be 130/80 with a normal heart rate of 70 as well as optimal oxygen saturation and temperature.  The vital signs have already returned to normal.  He was noted to be in no apparent distress, alert and oriented times three (x3), without respiratory distress and without pain. The physical examination revealed no oropharyngeal edema and normal pulmonary and cardiac examination.  

The subsequent treatments provided during the inpatient stay include social work evaluation, prescription for permethrin bath, oral diphenhydramine and continuation of his regular medications.  These services do not require and inpatient level of care.  Based on the lack of criteria for inpatient admission service such as: airway edema, stridor, respiratory distress, bronchospasm or hemodynamical instability, as well as the documented response and improvement of symptoms to the initial treatments in the emergency room, the level of inpatient admission does not meet medical necessity.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure (Magnetic Sphincter Augmentation [MSA]).

The insurer denied the LINX Procedure (Magnetic Sphincter Augmentation [MSA]).  The denial is overturned.

The patient is a woman with heartburn.  She has had GERD (gastroesophageal reflux disease) for the past several years and was found to have a hiatal hernia on upper endoscopy (abnormal), elevated esophageal acid exposure on esophageal pH (potential of hydrogen) monitor on the third of the four days of testing which is abnormal, and normal motility on barium esophagram as well as esophageal manometry.  She was recommended to undergo robotic LINX procedure.  She has tried PPI (proton pump inhibitor) and H2 (histamine 2) blocker. 

Yes, the health plan should cover the LINX Procedure.

Yes, the LINX Procedure is likely to be more beneficial.

This patient suffers from GERD causing profound symptoms.  Even with PPI there is refluxing gastric contents.  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA (Food and Drug Administration).  There is published data on patients who have had the device for many years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure (Magnetic Sphincter Augmentation [MSA]).

The insurer denied the LINX Procedure (Magnetic Sphincter Augmentation [MSA]).  The denial is upheld. 

This patient is a female.  She has a BMI (body mass index) 24.8 kg (kilograms)/m2 (meters squared).  She complains of medically refractory GERD (gastroesophageal reflux disease) for several years, despite PPI (proton pump inhibitor) and h2 (histamine 2) blocker intake.  EGD (esophagogastroduodenoscopy) revealed a small hiatal hernia without evidence of esophagitis or Barrett's esophagus.  UGI (upper gastrointestinal series) was completely normal with no evidence of hiatal hernia and no evidence of GERD (gastroesophageal reflux disease).  24-hour pH (potential of hydrogen) study was equivocal with only one out of four days documenting any significant GERD or elevated DeMeester score.  All other days were within normal limits with normal DeMeester score.  Esophageal manometry was normal. 

No, the health plan should not cover the LINX Procedure.

This patient has symptomatic GERD that is not clearly supported by diagnostic evaluation.  There is no evidence of GERD on EGD at two separate times a few years apart.  UGI shows no evidence of GERD.  The 24-hour pH (potential of hydrogen) study was not diagnostic for GERD with only one out of four days measuring any significant GERD.  Given that GERD is not clearly diagnosed on radiographic or endoscopic evaluation, there is concern that LINX or any surgical anti-reflux procedure may not be indicated and could result in unnecessary dysphagia or other issue without improvement in the patient's symptoms. 

No, the LINX Procedure is not likely to be more beneficial.

Classic GERD is not supported by UGI, EGD or 24 hour pH monitoring (which was equivocal).  LINX or surgical anti-reflux treatments therefore pose a higher risk of not improving this patient's symptoms, which may not necessarily be related to GERD.