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

Diagnosis: Heart disease, diabetes mellitus, hyperlipidemia, gastroesophageal reflux, osteoarthritis, stress incontinence, and glaucoma.

Treatment: Social Daycare Service (SDC) 2 days per week.

The insurer denied coverage for Social Daycare Service (SCD) 2 days per week.

The denial is upheld.

The patient has a history of heart disease, diabetes mellitus, hyperlipidemia, gastroesophageal reflux, osteoarthritis, stress incontinence, and glaucoma. Uniform Assessment Score (UAS) shows she is able to walk with the use of a cane. She is able to bathe and dress with limited assistance. She is able to manage personal care transfer on and off the toilet and use the toilet without any physical assistance. She is independent in bed mobility. She receives personal care services (PCS) and SDC. The request is to increase SDC to 2 days per week.

The New York State Office for the Aging Adult Social Daycare Services cite notes:

"... person who needs the assistance of another person in at least one of the following activities of daily living: toileting, mobility, transferring, or eating; or who needs supervision due to cognitive and/or psycho-social impairment. ..."

These needs are not documented as being active. There is no rationale given for the need for a second day of Daycare services. 	

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

The insurer's denial of coverage for Social Daycare Service (SDC) 2 days per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthritis, Hip

Treatment: Ambulatory surgery, hip replacement,

The insurer denied coverage for ambulatory surgery, hip replacement.

The denial is upheld.

This is a patient with a history of hypertension, arthritis, heavy tobacco abuse, and heavy alcohol use. She presented to the Orthopedic Surgeon's office for the evaluation of hip pain. Injections provided her with temporary relief. She takes Meloxicam every day. The patient has difficulties with daily activities and sleeping at night. Imaging revealed advanced arthritis in both hips. The physician recommended hip replacement surgery to treat arthritis. 

The medical records demonstrate indications for the total hip arthroplasty have not been met. The woman is a heavy smoker. The scientific literature has shown worse outcomes and increased complication rates in people who use tobacco. She would be at an increased risk for infection and at the very least pulmonary problems. It would not be unreasonable to cease smoking as recommended in guidelines. The letter of appeal has been taken into consideration. There are no extenuating circumstances to perform an arthroplasty at this time. 

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

Based on the above, the medical necessity for the ambulatory surgery, hip replacement is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near Syncope
Treatment: Hospital inpatient admission
The insurer denied coverage for hospital inpatient admission.
The denial is upheld.

The patient presented to the hospital with near syncope, visual changes, nausea, vomiting and shortness of breath. He was working all day in a hot environment without adequate hydration. Past medical history was significant for gastroesophageal reflux disease (GERD) and post traumatic stress disorder (PTSD) treated with Seroquel. On arrival, vital signs were stable, BP (blood pressure) 126/84 mmHg (millimeters of mercury) and Pulse 100 bpm (beats per minute). Physical examination was without abnormality. Serum blood testing revealed hypophosphatemia (0.9mg/dl [milligrams per deciliter]), potassium was 3.5 mg/dl, blood urea nitrogen (BUN) 9mg/dl and creatinine (CR) 1.12 mg/dl. 12 lead ECG (electrocardiogram) revealed normal sinus rhythm without ischemic changes. The patient was admitted to the hospital and treated with electrolyte repletion and intravenous fluids.

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. This patient presented with near syncope and vomiting after working in a hot environment. Upon arrival to the hospital, vital signs were stable. The patient was discharged the following day. This patient presented with near syncope due to volume depletion, a benign process. According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality (Reference 1). In a study of individuals presenting to the emergency room, patients that were low risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2). In this case, the patient falls into a low-risk category and could be managed a lower level of care.

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

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

Diagnosis: Atrial Fibrillation
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient hospital stay.
The denial is upheld.

This patient underwent elective electrophysiologic study with ablation of atrial fibrillation. 

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. This patient presented to the hospital for an elective electrophysiologic (EP) study and ablation of atrial fibrillation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% (percent) of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1). 

Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day (Reference 2).

The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.

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

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

Diagnosis: Genitourinary/Kidney Disorder/Chronic Kidney Failure/ESRD
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a past medical history (PMH) of end stage renal disease (ESRD) on hemodialysis (HD), coronary artery disease (CAD), diastolic heart failure (HF), and hypertension (HTN) who was admitted with complaints of a three-day history of left shoulder pain. Vital signs were remarkable for hypertension (HTN). A physical exam was notable for limited shoulder range of motion (ROM) secondary to pain. Lab work was notable for positive troponin, but stable. Imaging studies included a computed tomography (CT) of the chest which was negative for aortic dissection or pulmonary embolism (PE); a chest x-ray (CXR) showed mild pulmonary edema. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) and an old left bundle branch block (LBBB). The patient was diagnosed with shoulder impingement and was treated with steroids and physical therapy (PT)/occupational therapy (OT). The patient was discharged in stable condition.
What is at issue is the medical necessity of the inpatient level of care.

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

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of left shoulder pain that was not considered likely to be acute coronary syndrome (ACS) related, based upon documentation review, and the troponin elevation was thought most likely secondary to ESRD. An EKG did not demonstrate any acute ischemic changes. For the chest pain, the patient's HEART risk score was 6 (slightly suspicious, non-specific repolarization disturbance on EKG, >65YO and 1-3x elevated troponin), indicating that the patient had a moderate score, and not a high score. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG, and negative delta cardiac biomarkers, no new LBBB or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at an observation level of care.
Regarding the provided criteria, the patient did not have acute kidney injury, significantly elevated blood sugar, fever, need or mechanical ventilation, hypertensive emergency, or aortic dissection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, cellulitis, seizures, and pressure ulcers. 

Treatment: Personal Care Aide (PCA) services 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) for a total of 168 hours per week. 

The insurer denied coverage for personal Care Aide (PCA) services 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) for a total of 168 hours per week. 

The denial is overturned. 

The patient is an elderly male with multiple medical problems, recently hospitalized with diagnoses that included Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, cellulitis, seizures, and pressure ulcers.  He has a feeding tube, tracheostomy, and peripherally inserted central catheter (PICC) line.  Under review is the medical necessity of requested Personal Care Aide (PCA) services 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) for a total of 168 hours per week. 

The combination of the patient's multiple medical problems and the care required for his feeding tube, tracheostomy and peripherally inserted central catheter (PICC) line support the medical necessity of the requested 24-hour Personal Care Aide (PCA) services; 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) for a total of 168 hours per week.  The patient is dependent for activities of daily living, functional mobility and unable to self-care for his basic medical needs.  He lives with his disabled spouse who is unable to care for him.  He remains a significant risk for developing or extending pressure ulcers (requiring every 2 hour position changes) as well as oxygen desaturation that requires the need for ongoing respiratory observation/care. 

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 Personal Care Aide (PCA) services 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Mental Health 
Treatment: Outpatient Mental Health 
The insurer denied psychological testing. 
The denial is partially overturned.

At the time of service, the patient was a female referred for comprehensive psychological evaluation due to suspected bipolar disorder. She reported a very complex history of psychological problems, including depression, anxiety, substance abuse, obsessive-compulsive behavior, and disordered eating. She reported a history of sexual abuse. She also reported a history of trauma in both childhood and adulthood (e.g. [for example], father shot in the neck with resultant quadriplegia). Additionally, she endorsed current problems with insomnia. The health plan denied coverage for the evaluation due to a lack of medical necessity. The subject under review is the medical necessity for the psychological testing.

The requested service of psychological testing is medically necessary for this patient, in part. The patient has a very complex presentation with multiple historical and current problems and symptoms. A standard clinical interview would not be sufficient to address her multiple issues. Comprehensive psychological testing was clearly needed to differentiate among several diagnostic possibilities. Moreover, the diagnosis of bipolar disorder requires a careful review of the history, symptoms, course, and potential overlap with related disorders.

The records provided clearly establish the medical necessity for comprehensive psychological evaluation due to the complexity of the case and need to rule in/rule out related disorders in order to arrive at a proper diagnosis and treatment plan.
However, establishing the medical necessity of comprehensive psychological evaluation does not necessarily imply that this psychological evaluation was entirely medically necessary. The provider employed a broad array of measures, but not all of them are clearly necessary to arrive at a diagnosis and treatment plan. For example, there does not appear to be a sufficient rationale for inclusion of the following cognitive measures:

1) California Verbal Learning Test - Third Edition (CVLT-3) 2) Delis-Kaplan Executive Functioning System (D-KEFS) - selected subtests 3) Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV)

This was not a neuropsychological evaluation, and a comprehensive assessment of cognitive functioning was not clearly supported by the history and referral questions. It is fairly common for some of these measures to be included in a comprehensive psychological evaluation, but the present one did not clearly provide a rationale for cognitive assessment, and these measures were not medically necessary to rule in or rule out plausible alternative diagnoses.

This patient clearly needed a comprehensive psychological evaluation, and this is fully supported. 

As such, it would be reasonable and medically necessary to overturn the portion of the psychological evaluation medically necessary to arrive at a proper diagnosis and treatment plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission

The denial is upheld. 

This patient has a history of hypertension and diabetes. He presented to the hospital for elective cardiac catheterization following a positive stress test. Prior to stress testing, the patient reported symptoms of dyspnea and lightheadedness. Cardiac catheterization revealed non obstructive disease of the left anterior descending and left circumflex arteries and severe disease in the right posterolateral coronary artery. A drug eluting stent was placed in right posterolateral artery. No perioperative complications were noted, and the patient was discharged the following day. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented for elective percutaneous revascularization. He underwent an uncomplicated procedure and stents were placed in the right posterolateral artery. He was discharged the following day. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the (Reference1-4). Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care (Reference 4). 

In conclusion inpatient admission was not medically necessary. The patient could have been managed at a lower level of care. The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility. 
Treatment: IVF (in vitro fertilization) cycle. 

The insurer denied coverage for IVF cycle. 

The denial is upheld. 

This is a patient with a history of secondary infertility. She presented to the Reproductive Endocrinologist's for a new patient consultation. She reported trying to get pregnant with her partner for two years. An in vitro fertilization (IVF) cycle produced 8 oocytes. There were 2 blastocyst embryos that were aneuploid. The patient is requesting an additional IVF cycle. 

After consideration of the enclosed medical records, statements from this patient, her provider, and the insurance carrier, it is this reviewer's expert opinion to uphold this decision made by the insurance carrier.  Although this patient attempts to make a case that this denial is related to age discrimination, in fact the reviewer agrees with the insurance carrier because their decision is based more so on the probability of success in such a patient. This is a patient who will be of advance maternal age, and her anti-mullerian hormone (AMH) level is low (normal is considered 1.14) consistent with low ovarian reserve and her prior history and has a high probability of producing fewer or less eggs and/or blastocysts in the future, which is typically anticipated in these patients.  Furthermore, and more significant is this patient's extremely low probability of having a positive outcome (live birth) from either the IVF or IVF/PGT-A [Preimplantation Genetic Testing] for Aneuploidy treatment.   Many IVF programs nationwide do not offer IVF to women of advance maternal agae due to their low likelihood of becoming pregnant.  The rationale behind this is not related to this patient's age alone, but rather the medical findings related to her age.  For one, she has a low probability of producing an adequate egg count, and unfortunately this coupled with her high aneuploidy (abnormal genetic embryo) rate due to her age effecting her eggs, her overall success rate would be estimated to be less than 2% (percent).  In other words, rather than state this denial of coverage is related to this patient's age, one would say is related to a combination of this patient having a low ovarian reserve coupled to having a high aneuploidy rate.  The literature would state the prognosis for having a live birth delivery is extremely low in an advance maternal age, and almost nonexistent. 

There are many references that support and/or agree with the less than 2% success rate in a female patient with a low ovarian reserve.  The SART [Society for assisted reproductive technologies] registry annually would confirm such rates. 

Therefore, for the reasons cited above, the health care plan did act reasonably with sound medical judgement and in the best interest of this patient. 

The insurer's denial of coverage for an in vitro fertilization (IVF) cycle is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Heart Rate (bradycardia)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. She was hospitalized at the Inpatient Hospital level of care. She presented to her primary care provider's office for evaluation of intermittent weakness and lightheadedness and was found to have a HR (heart rate) in the 30s. Her beta-blocker (BB) drug was placed on hold. She was given IVF (intravenous fluids), insulin, calcium and D50W (50% dextrose in water) for borderline hyperkalemia of 5.6. She responded nicely and was discharged to home. This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

No, the proposed treatment is not "medically necessary".
Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the MCG (Milliman care guideline), Cardiology, criteria for inpatient admission is not met, including hemodynamic instability, syncope, myocardial ischemia, altered mental status that is severe or persistent, heart failure or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received, including withholding her beta blocker drug and correction of borderline hyperkalemia like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

According to the documentation submitted, this patient has a history of attention deficit disorder (ADD) and seasonal allergies. He had been sick for one month with coughing. Two weeks prior to admission, he was brought to his pediatrician who diagnosed an upper respiratory illness. He then developed a decrease in his oral intake and difficulty breathing the day before admission and was taken to the emergency room (ER) by his mother.

In the ER, he was noted to appear sick and lethargic. He was noted to get out of breath when talking. On physical exam, he was noted to have decreased air entry on the lower right lung and decreased breath sounds and wheezing in the left lung. A blood gas was obtained, which showed acidosis. A subsequent lactic acid level was elevated and a respiratory viral panel was positive for rhinovirus. He was treated with an intravenous (IV) fluid bolus and 3 doses of DuoNeb followed by continuous albuterol. He then required a dose of subcutaneous epinephrine, Decadron, and magnesium sulfate. A chest x-ray showed opacity in the lower right lung. He then required bilevel positive airway pressure (BIPAP). After treatment in the ER, he was reevaluated and found to have persistent wheezing in the left lung and the decision was made to admit him with a diagnosis of status asthmaticus for ongoing treatment with continuous albuterol and BIPAP with oxygen.

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

The patient was treated appropriately in the ER for a cough, wheezing and dyspnea when talking. He required continuous albuterol and respiratory support with BIPAP and oxygen. He was in respiratory failure with persistent wheezing and acidosis. 

Based on review of the medical record, it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with continuous albuterol and BIPAP. 

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.