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

Diagnosis: Memory loss 

Treatment: 78608- Brain imaging, positron emission tomography (PET); metabolic evaluation 

The insurer denied coverage for 78608- Brain imaging, positron emission tomography (PET); metabolic evaluation. The denial -upheld.

This patient is a male who is being recommended to undergo a PET scan of the brain.  The patient complained of paresthesia to the groin region from a previous herpes infection.  The patient did begin utilizing gabapentin.  The patient also complained of poor sleep.  The patient had complaints of generalized weakness and fatigue.  On physical exam the patient was alert and fully oriented.  The patient had a normal gait with normal reflexes.  There was 5/5 strength.  There were no tremors.  The request was made for a PET scan.  According to an appeal letter from the patient the requested scan was memory loss.  The patient stated he has a history of being exposed to very strong solvents.  The patient also detailed all the chemicals to which he was exposed are known to cause nerve and brain tissue damage.

From a neurological standpoint, the requested brain imaging, positron emission tomography (PET) is not medically necessary.  The provider requested authorization for PET scan because of memory loss.  However, the patient's neurological examination was normal.  There is no objective documentation of memory loss or any neuropsychological testing supporting mild cognitive impairment.  Therefore, the denial of coverage for 78608 Brain imaging positron emission tomography (PET) metabolic evaluation is not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for 78608- Brain imaging, positron emission tomography (PET); metabolic evaluation is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Headache
Inpatient hospital

The patient is a woman with a history of Wolf Parkinson White status post implantable cardioverter defibrillator (ICD) placement, deep vein thrombosis (DVT) on anticoagulation, epilepsy, vertigo, and paraplegia secondary to trauma, who was admitted to the hospital. She presented to the emergency department with dizziness, headache, and hearing changes. She had recently been discharged for viral like symptoms. She reported waking up that morning with vertigo and stated that the episode was similar to prior episodes. She also reported hearing ringing and decreased hearing. Vital signs showed blood pressure 82/48, heart rate 79, and temperature 97.9 Fahrenheit. On physical examination, she was well appearing, heart was regular, abdomen was soft, breath sounds were normal, and she had a positive Weber sign. Head computed tomography (CT) was negative. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The reason is that the patient presented with weakness but was hemodynamically stable, had no imaging evidence of acute stroke, did not have evidence of a brain lesion or cerebellar disease, did not have evidence of spinal cord injury, and had no evidence of acute seizure as a cause of her symptoms. She received medications that could have been provided orally and there was low suspicion for acute sepsis/infection as a cause of her presentation. These symptoms could instead have been diagnostically and therapeutically managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute L5-S1 herniated disc
Issue under review: Continued skilled nursing facility admission

Determination:
The Continued skilled nursing facility admission is not medically necessary.

The patient has a history of atrial fibrillation (on anticoagulation), hypertension, intractable pain, spinal stenosis and morbid obesity.  She was hospitalized for acute on chronic pain.  Workup showed an acute L5-S1 herniated disc.  She received intravenous steroids.  Neurosurgery advised no surgical intervention.  She was transferred to a skilled nursing facility for further care.  Her baseline was noted to have been independent with self-care and mobility without an assistive device.

Following transfer, the patient was moderate assist for upper body dressing.  She was max assist for lower body dressing.

A week later, the patient was ambulating five feet at max assist.

A month after transfer, the patient was noted to have a four pounds weight gain due to excessive caloric intake.

Two weeks later, the patient was ambulating 100 feet at stand by assist.  She was stand by assist for upper body dressing.  She was mod assist for lower body dressing and bathing.

A week after, she was ambulating 100 feet at stand by assist.  She was requiring verbal cueing.  She was set up for upper body dressing.  She was min assist for lower body dressing and bathing.

The patient felt she could not return home because her home is not wheelchair accessible.  Further therapy so she would no longer need a wheelchair was recommended.

The patient had undergone rehabilitation and had improved and essentially plateaued at a level where she was ambulating household distances at the stand by assist level.  She was continuing to require physical assistance for her lower body self-care activities.  She was gaining weight but she did not have any medical or nursing issues that required ongoing inpatient care.  Her care could have been provided in the community with custodial level assistance for her mobility, self-care and safety.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient has a history of chronic headaches and has been treated with gabapentin. She had previously been treated with a nerve block with positive results. Her treating physician is requesting treatment for another injection with another due to the reoccurrence of occipital headache pain. 

Occipital nerve blocks are widely accepted as potentially effective treatment for occipital neuralgia.  Therefore, the scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

Per Tang Y1, et al. (2017), "Six RCTs were included in the meta-analysis.  Overall, compared with control intervention in migraine patients, GON block intervention was found to significantly reduce pain score (Std. mean difference=-0.51; 95% CI=-0.81 to -0.21; P=0.0008), number of headache days (Std. mean difference=-0.68; 95% CI=-1.02 to -0.35; P<0.0001), and medication consumption (Std. mean difference=-0.35; 95% CI=-0.67 to -0.02; P=0.04), but demonstrated no influence on duration of headache per four weeks (Std. mean difference=-0.07; 95% CI=-0.41 to 0.27; P=0.70)."

Per Shauly O1, et al. (2019), "Greater occipital nerve blocking should be recommended for use in migraine patients, particularly those that may require future surgical intervention.  The block may act as an important stepping stone for patients experiencing migraine headache because of its usefulness for potentially assessing surgical candidates for nerve decompression."

Kocer A1. (2016), "Hereby we noticed a remarkable success with refractory chronic migraine patients. We believe that this intervention can result in rapid relief of pain with the effects lasting for perhaps several weeks or even months."      

Occipital nerve blocks are widely accepted as potentially effective treatment for occipital neuralgia. The patient has a diagnosis of chronic headache.  The patient has benefited from occipital nerve blocks in the past. This is the best available treatment for this patient at this time.   Therefore, the requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient.     

The carrier's denial of coverage for Current Procedural Terminology (CPT) code 64405 [Injection, anesthetic agent; greater occipital nerve] and Healthcare Common Procedure Coding System (HCPCS) code J3301 [Injection, triamcinolone Acetonide, not otherwise specified, 10 milligrams (mg)] should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a female patient with a history of chronic headaches; occipital neuroglia. It was reported that her pain is in her left occipital area that radiates to the left side of her head. The patient received an occipital nerve block. It was reported that the patient had immediate relief after the injection. 
From UpToDate: " a local occipital nerve block (usually a mixture of a local anesthetic plus a glucocorticoid) is usually the treatment of choice among practitioners experienced with this procedure, since it has the potential of being both diagnostic (see 'Diagnosis' above) and therapeutic [17,31].  The nerve blocks should be performed by physicians, most often pain specialists, who are properly trained in the procedure.  Following occipital nerve block, pain relief is typically prompt and may last several weeks or even months.  The procedure can be repeated when pain recurs [8,17]."

This patient is a good candidate for CPT code 64405 [Injection, anesthetic agent; greater occipital nerve] and HCPCS code J3301 [Injection, triamcinolone Acetonide, not otherwise specified, 10 mg].  Oral medication makes her too sleepy and is less effective than the injections. It is the best available treatment for this patient at this time and it is likely to be more beneficial than any other standard treatment/procedure.

The carrier's denial of coverage for Current Procedural Terminology (CPT) code 64405 [Injection, anesthetic agent; greater occipital nerve] and Healthcare Common Procedure Coding System (HCPCS) code J3301 [Injection, triamcinolone Acetonide, not otherwise specified, 10 milligrams (mg)] should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Headache

Treatment: 64405 [Injection, anesthetic agent; greater occipital nerve] and HCPCS code J3301 [Injection, triamcinolone Acetonide, not otherwise specified, 10 mg]

The insurer denied the 64405 [Injection, anesthetic agent; greater occipital nerve] and HCPCS code J3301 [Injection, triamcinolone Acetonide, not otherwise specified, 10 mg]. The denial was reversed.  

This is a female patient with a medical history of hypertension and tinnitus. She presented to her neurologist with complaints of continued pain in the left occipital area radiating to the left side of the head and a tender spot in the left occipital. She underwent an occipital nerve block to the target area in the sub-occipital region on the left side. She tolerated the procedure well with noted relief. 

The scientific evidence and peer-reviewed literature supports a result of improvement in health outcomes.  There is strong scientific support for the use of occipital nerve blocks to treat occipital neuralgia, and this procedure is considered standard of care as a frontline treatment for occipital neuralgia. The Current CPT code for injection and medication has the approval from the appropriate regulatory bodies for this diagnosis.  The treatment is the standard CPT code used for this diagnosis. 

The patient is a good candidate for Current Procedural Terminology (CPT) code 64405 [Injection, anesthetic agent; greater occipital nerve] and Healthcare Common Procedure Coding System (HC PCS) Code J3301 [Injection, triamcinolone acetonide, not otherwise specified, 10 milligrams (mg)].  The patient has derived positive clinical responses in the past with occipital nerve blocks and this procedure is considered a standard of care treatment for occipital neuralgia.

The requested service is likely to be more beneficial than any standard treatment/procedures for this patient.

The carrier's denial of coverage for Current Procedural Terminology (CPT) code 64405 [Injection, anesthetic agent; greater occipital nerve] and Healthcare Common Procedure Coding System (HCPCS) code J3301 [Injection, triamcinolone Acetonide, not otherwise specified, 10 milligrams (mg)] should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Pneumonia
Inpatient Hospital

The patient is a female with a medical history of colon cancer status post resection, hypertension, hyperlipidemia, anxiety and depression who was admitted for pneumonia with symptoms of abdominal pain, fever, anorexia, diarrhea and altered mental status. She was found to have pneumonia in the right middle and right lower lobes. Her condition improved with therapy including; intravenous antibiotics for pneumonia, deep vein thrombosis prophylaxis, monitoring of oxygen saturation with frequent oximetry monitoring and intravenous fluid resuscitation while hospitalized.

The health plan's determination is overturned. The inpatient stay was medically necessary. Based upon the severity of illness and intensity of required therapy, the inpatient level of care was medically necessary. This patient had a medical history of colon cancer status post resection, hypertension, hyperlipidemia, anxiety and depression who was admitted for community acquired pneumonia with symptoms of abdominal pain, fever, anorexia, diarrhea and altered mental status.

On admission, the patient was hemodynamically stable with an oxygen saturation of 97% on room air, respiratory rate of 20 breaths per minute but was febrile (103.6 F), had rhonchi bilaterally and was confused. She was found to have pneumonia in the right middle and right lower lobes on computed tomography (CT) scan and hyponatremia to 129 mEq on laboratory testing. In addition, her CURB-65 score was 2 and Pneumonia severity index (PSI) score was class 5, putting her at high risk for adverse outcomes and outpatient treatment would not be appropriate. Her condition required intravenous antibiotics for pneumonia, deep vein thrombosis prophylaxis, monitoring of oxygen saturation with frequent oximetry monitoring and intravenous fluid resuscitation while hospitalized. Therefore, based upon the high-risk co-morbidity of pneumonia based on her Pneumonia Severity Index (PSI) score, the entire inpatient hospital admission was medically necessary in accordance with generally accepted standards of medical practice based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient stay

Summary:
The patient is a male. He has a past medical history significant for COPD (chronic obstructive pulmonary disease), systolic CHF (congestive heart failure), s/p (status post) AICD (automatic implantable cardioverter defibrillator), CAD (coronary artery disease), HTN (hypertension), hepatitis C, liver cirrhosis, ICD (implantable cardioverter defibrillator) wire thrombus (not anticoagulated), medical non-compliance and polysubstance abuse, who presented to the ER with complaints of chest pain and dyspnea after a recent cocaine use. 

The patient presented with symptoms of acute CHF exacerbation, with known severe systolic dysfunction and CAD. His troponin was elevated, consistent with myocardial injury, which increases the risk of adverse cardiac outcomes. The patient also had symptoms of chest pain in the setting of recent cocaine use, with suspected vasospasm and resultant ACS (acute coronary syndrome). This patient has multiple co-morbidities and presented with CHF exacerbation. He was appropriately treated with IV diuresis. Although the patient subsequently signed out against medical advice, the clinical decision was made by the treating providers to admit the patient to an inpatient setting in this circumstance. Given this presentation, acute CHF, as well as multiple risk factors, co-morbid conditions and elevated cardiomarkers/troponins, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer

Treatment: Consumer Directed Personal Care Assistance (CDPCA) increase to 49 hours per week.  

The insurer denied consumer directed personal care assistance increase to 49 hours per week.  The denial was reversed. 

This is a female patient with a history of breast cancer, heart failure atrial fibrillation, hypertension (HTN), diabetes (DM), osteoarthritis (hands, knee, hip, spine), gait abnormality. The patient was recently diagnosed with breast cancer and is receiving hospice care. It was reported that the patient lives with her great-grandchild as all of the patient's children have passed. The patient's chronic medical conditions have contributed to her functional decline creating the need for assistance with all areas of care with her activities of daily living (ADLs). A request was made for an increase in consumer directed personal care assistance to 49 hours per week.

The patient was seen recently by her physician who he provided detailed description of the patient's functional status, including: Patient has shortness of breath with exertion < 1 block (patient has h/o heart failure). Patient has osteoarthritis, noted as severe OA of her knees (with valgus deformity); also has hip pain. Gait is noted as unsteady. It is difficult for patient to stand for long time. She uses wheelchair outside of home. Patient also has pain, stiffness and deformity of hands due to osteoarthritis (OA) - RA negative. This limits her hand function for tasks such as buttons and opening bottles. 

The goals of care for the patient include comfort and trying to maintain some quality of life for as long as possible. This includes keeping the patient safe, and relieving the burden of performing daily activities.
The patient needs assistance with mobility related ADLs. Dyspnea and pain are stressful symptoms; and providing assistance can ease some of the work required for movement. 

The patient needs extensive assistance for transfer on and off the toilet and toilet use.  The patient had infrequent urinary incontinence. Another aspect of providing comfort as well as preventing incontinence associated skin damage (e.g. dermatitis, fungal infection). 

Due to the patient's difficulty with mobility, she is at high risk for falls. Providing assistance with mobility related ADLs (walking, transfers, toileting) is an appropriate intervention to help decrease the occurrence of her falls. Falls in the elderly have a higher risk of serious injuries (e.g. fractures, head trauma) and are associated with substantial morbidity and increased risk of death. 

The patient has several medical conditions (as noted above) that have resulted in substantial functional impairment. The patient needs assistance with all mobility related activities, which includes ADLs that occur throughout the day (i.e. transfers, walking, toileting/incontinence care). 

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

Based on the above, the medical necessity for (The Issue) is substantiated/ not substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma right thigh
Treatment: Air ambulance services
The insurer denied the air ambulance services.
The denial is overturned.

The Ambulance services provided were medically necessary.

The patient is a male. He was using a rope swing in Aruba when he fell into the water and heard a crack to his right thigh.  He previously had undergone a total hip replacement (THR). He was transported to hospital and diagnosed with a periprosthetic femur fracture. He was reported to require specialized care and was transported for definitive management. 

The patient sustained a complex orthopedic condition which required specialized operative intervention. He was found to have a femur fracture and previous total hip replacement. He was found to have a cracked cement mantle and required revision arthroplasty. His physician removed the femoral component, exchanged the poly of socket and provided definitive fixation to the fracture. This type of surgery is requires treatment by a specialist in revision arthroplasty and trauma. This type of surgery would be best performed in a tertiary center. This kind of treatment would not be likely available in Aruba. 

Specialized transport would be necessary, as the patient's leg would not be stable. He would require splinting and pain medication. He would require monitoring as provided. He would be at increased risk for clot.

These facts would limit the patient's ability to utilize commercial transportation. Therefore, given the above, the Ambulance services provided were medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient stay

Summary:
The patient is a male with polysubstance drug abuse. He presented to ED with request for referral to detoxification center. 

While in the ER, the patient had sharp left-sided chest pain. EKG (electrocardiogram) showed nonspecific changes. Troponins were negative. He was administered ASA (aspirin) and Librium. The patient was admitted for treatment of withdrawal, and received Morphine for pain. 

There was no evidence of ischemia, and the patient was transferred for inpatient detoxification after being seen by psychiatry.

This patient self-referred to ER for treatment of and referral for detoxification for his polysubstance drug abuse. While in the ED, he stated that he had sharp chest pain. There was no objective evidence of ischemia. EKG during chest pain showed no acute findings. Cardiac enzymes were negative. No other testing for or treatment of ACS (acute coronary syndrome) is documented to have been done. Psychiatric consultation facilitated a transfer to another facility for detox treatment.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram was not ordered. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).
   
The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

The appeal statement that the care that was provided could not safely be provided at a lower level of care is not consistent with community practice or guidelines. All testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.