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


Diagnosis: cardiomyopathy/heart failure
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: 16 Hours per Day / 7 Days per Week - Total Amount of 112 Hours per Week 
The health plan's determination is overturned.

The patient is a male with past medical history of hypertension, cardiomyopathy, systolic heart failure, pulmonary hypertension, chronic obstructive pulmonary disease (COPD) with oxygen dependence, prediabetes, hyperlipidemia, carotid stenosis, benign prostatic hyperplasia (BPH), chronic kidney disease, atrial fibrillation, urinary incontinence, bowel incontinence, history of laryngeal cancer with total laryngectomy, and history of oropharyngeal cancer who had been assigned PCA (personal care aide) services.

Personal Care Aide (PCA) Services: 16 Hours per Day / 7 Days per Week - Total Amount of 112 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCA services. There is documentation that the patient's informal support can no longer provide the same level of informal support due to the caregiver's age and stamina. The patient requires total assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs and the insurer failed to document a plan to meet the patient's care needs when the PCA and informal care is not available. The patient's care needs are not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). 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, the requested PCA services 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 his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: knee pain
Treatment: pain management
The insurer denied Hyaluronan Injections 
The health plan's determination is upheld. 

This case describes a male patient with a complaint of left knee pain. The provided medical records document that the patient had a left knee meniscal tear associated with osteoarthritis. The patient's provider recommended hyaluronan injections. 

The requested Hyaluronan injections are not medically necessary for this patient. The records document that the patient's orthopedic surgeon recommended hyaluronan injections to treat his left knee osteoarthritis. The peer-reviewed literature, however, has not endorsed viscosupplementation injections as an effective treatment modality for knee osteoarthritis.
An article published by Tammachote and colleagues in the Journal of Bone and Joint Surgery compared a hyaluronic acid injection to a corticosteroid injection. The authors concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second article published by Jevsevar and associates found that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo." Therefore, based upon the conclusions of these peer-reviewed studies, the medical necessity of the requested hyaluronic acid injections for this patient's left knee is not established in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute pancreatitis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned

The patient has a history of alcoholic pancreatitis and was continuing to drink daily. The patient presented to the emergency room (ER) with abdominal pain. The patient was afebrile but had hypertension. Epigastric tenderness was present without rebound or guarding. The lipase was 1900. A computed tomography (CT) scan showed acute pancreatitis along with ascites and diffuse mesenteric edema. The patient was made nothing by mouth (NPO) and given intravenous (IV) hydration. The patient did not want to be evaluated by addiction medicine. The abdominal pain improved.

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-250 for Pancreatitis clinical indications for admission for acute pancreatitis include having 2 of the following: Abdominal pain, serum lipase greater than 3 times the upper limit of normal, end imaging findings indicative of acute pancreatitis. In this case, the patient had abdominal pain, the lipase was greater than 3 times the upper limit of normal, and the CT scan read as showing evidence of acute pancreatitis. This met MCG criteria for admission for Pancreatitis. 

Based on the above, the insurer's denial must be reversed. 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 inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient no past medical history (PMH) who was admitted with complaints of (c/o) dizziness worse with positional changes. Her vital signs were unremarkable. The physical exam was notable for an unremarkable neurological examination. Lab work was unremarkable. Imaging studies, magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA) of the head, magnetic resonance angiography (MRA) of the neck showed no acute infarction or other intracranial findings, computed tomography (CT) scan of the head showed no acute pathology, computed tomography (CT) scan of the chest showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without acute ischemia. The patient was diagnosed with vertigo secondary to chronic otitis media (OM) and treated with meclizine, Ativan, physical therapy (PT) / occupational therapy (OT), and ear drops. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with dizziness and vertigo associated with nausea and vomiting. The patient did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. All imaging performed showed no acute intracranial pathology. The patient was treated with meclizine, Ativan, PT/OT, and ear drops. Given the patient's clinical stability and provided interventions and clinical monitoring, these could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal ideation, obesity, IDDM (insulin-dependent diabetes mellitus), hypertension, depression, atrial fibrillation, pneumonia, COVID-19, chronic pain syndrome, anxiety disorder
Treatment: 8 Skilled Nursing Visits
The insurer denied: 8 Skilled Nursing Visits
The denial is upheld.

The patient is an adult female with multiple medical issues, including suicidal ideation, obesity, IDDM (insulin-dependent diabetes mellitus), hypertension, depression, atrial fibrillation, pneumonia, COVID-19, chronic pain syndrome, anxiety disorder associated with phobias including agoraphobia, etc. The request is for a Visiting Nurse Service (VNS) in Skilled Nursing for the patient's mental health as an extra layer of support and to evaluate and develop a plan of care for her multiple co-morbidities. The request is for five additional VNS (Visiting Nurse Service) visits to correlate with other caregivers helping the patient manage her morbidities and comply with her medications. She was previously approved for 7 VNS (Visiting Nurse Service) visits 3 months ago that ended last month. The patient lives with her husband, who is intellectually disabled and also has mental health issues. The extra VNS (visiting nurse service) visits were denied coverage by the health plan, because the patient had 28 visits previously to help manage her medications, etc. Therefore, additional VNS (visiting nurse service) visits were deemed to be not medically necessary.

The 8 Skilled Nursing Visits are not medically necessary.

The requested VNS (visiting nurse service) visits to help manage medications and teach family members on how to do this is not medically necessary, because the patient was previously approved for 28 days, of which the most recent was approval for 7 VNS (visiting nurse service) that ended last month. The total number of previously approved VNS (visiting nurse service) visits to address the issues is deemed adequate for family members to continue to help her. Additional visiting nurse service visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Custom fabricated abutment-included placement.
The insurer denied custom fabricated abutment-included placement.
The determination is overturned.

This is a male patient who presented for the treatment of missing teeth number (#) 27,28,29 and 30. Provided for review are letters of appeal and denial, a letter from the treating provider, a narrative from the patient, health plan language, radiographic images, American Dental Association (ADA) claim forms, and explanation of benefits letters. At issue is the medical necessity of custom fabricated abutment - included placement. At issue is the medical necessity of custom fabricated abutment-included placement.
The requested health service/treatment of Custom fabricated abutment - included placement, is medically necessary for this patient. As the patient is missing teeth, he has the diagnosis of diminished posterior support as well as partial edentulism. With the diagnosis of partial edentulism as well as diminished posterior support the only therapy capable of addressing both diagnosis is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load. As the implants have already integrated they will require restorations in the form of abutments and crowns in order to complete the tooth replacement and replace the teeth and support for the dentition. This is standard in tooth replacement involving implants. Placement of a partial denture on integrated implants is contraindicated and fails to utilize the implants as intended. Hence the request treatment is medically necessary. The custom abutment (6057) is part of the required components in order to restore the missing tooth. Based on the prosthesis and the need to fit into the arch, a standard abutment cannot be utilized making the custom abutment medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dark urine and diffuse joint pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult male with past medical history significant for hypertension and hyperlipidemia, who presented to the emergency department with complaints of dark urine and diffuse joint pain. 

Vital signs on presentation included: Temperature (max) 100.5 degrees Fahrenheit, Blood Pressure 111/74 mmHg, Pulse 120 beats per minute, Respirations 19 breaths per minute, and oxygen saturation 97% on room air. Laboratory results included the following; white blood cell (WBC) count 16.52, hemoglobin (Hgb) 13.5, hematocrit (Hct) 40.3, creatinine 1.1, glucose 110, C-reactive protein (CRP) 11.5, erythrocyte sedimentation rate (ESR) 44. Chest X-ray (CXR) was negative.

The patient was started empirically on intravenous antibiotics (ceftriaxone and doxycycline) and intravenous fluids. Infectious Diseases consulted and cultures were sent. The patient improved clinically, remained afebrile and hemodynamically stable. He was discharged to continue outpatient management on oral antibiotics.

According to the documentation, the patient presented with fever and polyarthralgia. The patient was febrile with an elevated heart rate. Laboratory results were notable for elevated white blood cell (WBC) count and inflammatory markers. Based on the above abnormal findings in a patient with co-morbid conditions and uncertain etiology of infection, hospital admission was 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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient for whom an inpatient hospitalization is under review. There was a history of coronary artery disease (CAD), hypertension, and hyperlipidemia. He presented for an elective staged intervention of the left anterior descending (LAD) and diagonal arteries. His prior percutaneous coronary intervention reported significant improvement of his dyspnea on exertion. He underwent a successful and uncomplicated procedure. His vital signs were essentially normal. The creatinine was normal. He remained stable and was discharged. At issue is the medical necessity of an inpatient hospital stay.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic low back pain

Treatment: pain management services/spinal cord stimulator, 18 units

The insurer denied coverage for pain management services/spinal cord stimulator, 18 units

The denial is upheld 


This is an adult patient with chronic low back pain. The patient has had physical therapy and a home exercise program. The patient's medication trials have included Suboxone, Gabapentin, Hydrocodone, Mobic as well as Ketamine and Lidocaine infusions. The patient had an Epidural steroid injection (ESI).  The patient had a psychiatric exam and was cleared for "surgery". The patient's magnetic resonance imaging (MRI) shows multi-level spondylosis, thoracic vertebral body fractures, and spinal stenosis. There is no past surgical intervention. The request is for spinal cord stimulation trial.
 
Mekhail et al (1) conducted a systematic review for various indications.  Patients with back pain without prior surgery have weak support in comparison to Failed back surgery syndrome.

Eckerman et al (2) conducted: "A systematic literature search was performed to identify studies reporting outcomes for spinal cord stimulators (SCS) in chronic back pain patients (with or without secondary radicular leg pain) without prior surgery using date limits from database inception to February 2021. Study results were analyzed and described qualitatively. A total of ten primary studies (16 publications) were included. The included studies consistently demonstrated favorable outcomes in terms of pain reduction and functional improvement following SCS therapy. Improvements also occurred in quality-of-life scores; however, not all studies reported statistically significant findings. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for pain management services/spinal cord stimulator, 18 units services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female who was admitted for positive bacteria in the urine. This was a recurrent issue for which she was treated with intravenous (IV) antibiotics. An IV (intravenous) line was placed, and she was started on antibiotics. She tolerated treatment well and remained hemodynamically stable. 

The inpatient hospital admission was not medically necessary. The patient was admitted for urinary tract infection. She has history of resistant bacterial infection which responds well to IV antibiotics. During this hospital stay, the patient remained hemodynamically stable and responded appropriately to antibiotics therapy. The medical records did not show that she has persistent infection, severely abnormal vital signs or severe sepsis which required inpatient level of care.
Patients with an uncomplicated urinary tract infection (UTI) (e.g., no fever, no flank pain) are treated as outpatients (if no other indication for admission is present). (1,2)
Some patients with an uncomplicated upper UTI (e.g., hemodynamically stable, able to maintain hydration orally) do not require inpatient admission. (3)
Database analysis including 572,479 adult visits to an emergency department for UTI found an inpatient admission rate of 17% (percent). (4)
Another analysis of a national database found that out of more than 1.5 million visits to the emergency department for pyelonephritis, 27% were admitted to inpatient care. (5)
Therefore, per standard of care and evidence-based literature, inpatient admission was not medically necessary and lower level of care was more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female who presented to the emergency department (ED) with a complaint of abdominal pain, nausea and vomiting. She had undergone a colonoscopy two days prior to this presentation. Her past medical history includes hypothyroidism. She was admitted to the hospital. Her vital signs were normal at the time of presentation. She was tender in the right upper quadrant. The white blood cell count (WBC) count was elevated at 20 thousand (K). Liver enzymes were normal, alkaline phosphatase was elevated at 138. An ultrasound showed a gallbladder with stones and findings of acute cholecystitis. The surgical history and physical (H&P) states that the patient had cholecystitis for which laparoscopic cholecystectomy was planned. She was treated with nothing by mouth (NPO) status and intravenous (IV) antibiotics. Surgery was performed. The operative notes describe a laparoscopic cholecystectomy for the diagnosis of acute cholecystitis. Laparoscopic cholecystectomy was performed without complication.
The diet was advanced and she was continued on IV antibiotic. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of an inpatient stay.
This patient presented with a complaint of abdominal pain, nausea and vomiting. Presurgical physical examination, imaging and lab data supported the diagnosis of acute cholecystitis and the operative findings confirmed that there was acute cholecystitis. The patient required pre-surgical antibiotics. She required provision of post-surgical intravenous (IV) antibiotics to treat the acute infectious/inflammatory condition. The early post-surgical recovery was uncomplicated.
In this case there is documentation of acute cholecystitis. Her condition responded promptly to the treatment provided (intravenous (IV) antibiotics and cholecystectomy). The severity of disease, her response to therapy, and her ability to achieve discharge criteria within one day following surgery did not support the medical necessity of inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have appropriately been rendered with a lower level of care during this time.