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

Diagnosis: Shortness of breath
Treatment: Inpatient admission

The proposed treatment was not medically necessary.

The patient was in mild COPD exacerbation which improved significantly with emergency room care. The patient was started on oral steroids and nebulization at the time of admission.  Since patient's condition improved significantly with emergency room care and patient was discharged after one day length of stay, the acute in patient level of care does not meet medical necessity.  The acute in hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of an acoustic neuroma status post resection in 2003 resulting in single sided deafness and tinnitus on the Left side. Recent audigram shows normal hearing in the Right ear. The patient reports that the unilateral deafness has caused a significant impact in the patient's ability to communicate/function at work. The patient had been prescribed a CROS hearing aid that the patient does not wear on a regular basis (ineffective to improve functional hearing). A cochlear implant is being requested. The health plan denied the unilateral implant because the patient did not have bilateral deafness. This is the subject of this review.

The health plan's determination is overturned. The cochlear implant is medically necessary for this patient. The Food and Drug Administration (FDA) has approved cochlear implants for single sided deafness. The patient was found to have limited benefit from a CROS hearing aid and meets the surgical criteria for a cochlear implant.The patient had a promontory stimulation testing that showed that the patient was able to transmit an auditory signal to the brain. The current research suggests that cochlear implantation is appropriate for patients to improve sound localization, improved hearing, and tinnitus suppression.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe headache
Treatment: Inpatient admission
The proposed treatment (inpatient admission) was not medically necessary.

Following this patient's ED evaluation, she was clinically stable. She had presented to the ED with a recurrence of chronic migraine headaches. There was no suspicion that her headache was a symptom of some acutely dangerous medical condition. While in the ED, the patient had a near syncopal episode. She was found to be hypotensive and bradycardic. Both the ED note and the admission note for this patient attributes her near syncope to the blood pressure medications she had taken before coming to the hospital. With IV fluid given in the ED, the patient's vital signs normalized. The admission note for this patient indicates that she would be kept on a cardiac monitor. She would have repeat blood tests and repeat EKG. There was no plan to perform a cardiology evaluation or a neurologic evaluation.

At the time the decision was made to keep this patient a hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a short stay in the hospital. For this reason, an inpatient admission was not medically necessary. The patient could have safely and effectively been managed at an observation level of care.

There was no severity of illness present to justify an inpatient admission. When the patient left the ED, she had normal vital signs. The transient hypotension she experienced in the ED had resolved with IV fluids. There was no suspicion of an acute coronary syndrome or neurologic emergency. There was no intensity of services required for the patient to justify an inpatient admission. She would be kept on a cardiac monitor overnight. The following day she would have repeat blood tests and an EKG. No other testing or consultations were planned for the patient.

In conclusion, the patient was clinically stable following her ED evaluation. A limited plan of care was anticipated for. An inpatient admission was not medically necessary for this patient. She could have safely and effectively been managed at an observation level of care. The Health Plan did act reasonably in denying coverage for this inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission 

Summary:
The patient is a male with history of asthma. He presented to the emergency room with wheezing and shortness of breath. 

The patient's asthma exacerbation improved significantly with emergency room care. The patient was hemodynamically stable, and he was able to speak in full sentences. The patient was ambulating without assistance and did not require supplemental oxygen. The patient was discharged home after one day length of stay. The acute in-hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait instability; dizziness; arthritis; impaired vision,

Treatment: increase in personal care assistance from 30 hours to 35 hours per week

The insurer denied coverage for increase in personal care assistance from 30 hours to 35 hours per week.  The denial was reversed.

This patient is a female with diagnoses: hypertension, chronic obstructive pulmonary disease (COPD), asthma, gastroesophageal reflux disease (GERD), hyperlipidemia, fatty liver, depression, lumbar radiculopathy, chronic kidney disease (CKD), osteoarthritis of knees, memory loss, and Vitamin D deficiency.  The patient has increased fatigue, dizziness, abnormal gait, generalized pain which increases risk of falls.  The patient needs additional home health aide hours.

A substantial cause of the patient's functional impairment is the limitation of mobility due to chronic pain, stiffness and decreased range of motion from arthritis, degenerative disc disease and lumbar radiculopathy.  In the UAS and physician's records the patient reports pain varying from 4 to 10.  Location of pain is noted as knees and back.  The medication list from her physician includes gabapentin and naproxen PRN.  Recent consideration was given to starting Cymbalta (not known if this was ordered).  She also has had physical therapy and epidural injections.  Other physicians involved in her care include orthopedics, rheumatology and neurology (records not available).  In the Case Management supplement it was noted that the patient is unable to lift, bend and carry.  She was observed having difficulty standing up from a seated position. 

As per the UAS, the patient is receiving PCA services 6 hours per day x 5 days per week.  An additional 5 hours per week (35 total hours as requested) will not provide 6 hours per day x 7 days per week.  The amount of hours that can be recommended for approval from this review is limited to the number of hours requested.  Therefore, the maximum number of PCA hours recommended for approval is 35 per week.  The number of hours per day should be distributed to provide optimal benefit for the patient's daily needs.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the increase in personal care assistance from 30 hours to 35 hours per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The records do not support that inpatient admission was medically necessary.  The care and treatment provided to this patient could have reasonably been administered with a lower level of care (rather than acute inpatient admission).

This patient presented to the ED with abdominal pain and was diagnosed with cholelithiasis/cholecystitis. The patient was clinically stable at the time of presentation and remained stable throughout the hospitalization.  The initial WBC count was normal.  Serum transaminases were elevated, but MRCP was without findings of CBD stones.  The patient responded promptly to initial treatment and laparoscopic cholecystectomy.  She was discharged from the hospital with instructions for surgical follow up.

Based on the available medical record the medical necessity of inpatient admission is not established.  The records support that this care and treatment provided could have been completed in a lower level of care setting. This level of care would have allowed for provision of the medical treatment that was rendered in this case (including overnight observation if needed).  There is no documentation of clinical condition that required inpatient admission such as hemodynamic aberration, fever, WBC count > 10 K, elevated C-reactive protein, cholangitis, vomiting/severe dehydration, bowel obstruction or severe pain that required hospital admission.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of near-drowning with subsequent hypoxic ischemic encephalopathy. The patient required a tracheostomy tube placement and only recently was decannulated, leaving the stoma uncovered and wide open per doctor's orders. Despite being decannulated, the patient cannot tolerate secretions and has no functional swallow/gag reflex. The patient requires frequent suctioning, almost hourly, as well as albuterol treatments and chest physiotherapy. The patient is gastrostomy dependent for all fluids and nutrition. The patient has copious oral secretions and severe gastroesophageal reflux, with frequent vomiting during and in-between feedings. The patient is maintained in a thera-suit covering her from neck to above the knees to encourage proper alignment and prevent scoliosis, necessitating frequent temperature and skin assessments. The patient is non-verbal, non-ambulatory, legally blind, with severe global developmental delay and slow progress to date. Skilled nursing needs include gastrostomy care and feedings, maintenance of aspiration precautions, tracheostomy stoma care, continuous monitoring of the airway with suctioning and respiratory treatments and chest physiotherapy, administration of routine and as needed medications, close monitoring of vital signs and skin integrity while in the thera-suit, continuous monitoring of pulse oximetry with application of supplemental oxygen as needed, and performance of all activities of daily living.

The health plan's determination is overturned. The Private Duty Nursing (PDN) for 24 Hours/Day, 7 Days/Week is medically necessary for this patient. The patient has a number of medical problems as a result of  near-drowning last year. Of greatest concern is the tenuous airway. The patient no longer has a tracheostomy, but produces copious secretions and is unable to swallow or clear secretions. The patient requires continuous round-the-clock monitoring with frequent suctioning to prevent aspiration and the complications of aspiration (eg pneumonia, respiratory failure, sepsis). The patient is dependent upon gastrostomy tube feedings for nutrition and fluids, with a period of continuous feeding overnight and measured administration throughout the day (eg use of a feeding pump). The patient has severe gastroesophageal reflux despite maximum medical management and vomits in between and during feedings. This also places her at significant risk of aspiration if not monitored constantly with skilled intervention as needed (eg suctioning up to multiple times an hour). The requested skilled nursing services 24 Hours/Day, 7 Days/Week are medically necessary and appropriate to provide the care and expertise that this patient needs to maintain health and prevent morbidity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy with quadriplegia
 
Treatment: 168 hours per week of Private Duty Nursing Licensed Practical Nurse (LPN)

The insurer denied the 168 hours per week of Private Duty Nursing Licensed Practical Nurse (LPN). The denial was reversed.    

This is a male patient with a significant medical history: Cerebral Palsy with quadriplegia, unspecified hydrocephalus, chronic obstructive pulmonary disease (COPD), seizure disorder, dysphagia, orthostatic hypotension, generalized muscle weakness and gastroesophageal reflux disease (GERD). He is status post aspiration pneumonia. He is Trach dependent for Ventilator Dependent Respiratory Failure (VDRF) as well as had a percutaneous endoscopic gastrostomy (PEG). Despite the patient's multiple medical co-morbidities, he is stable enough to transition home with 24 hour skilled nursing. 

The patient's Medical Doctor (MD) who has been following him feels that this patient is stable enough despite his multiple medical issues to be transitioned to his home with 24 hour Skilled Nursing.  The patient's family is involved in his care, and has been also trained in managing the patient.  They are also willing to be rescue care providers in case there are issues with daily nurse coming in and have signed to the fact and also have a roster of care.

This patient can be discharged to his home with 24 hour Skilled Nursing care.  In case it becomes unmanageable the patient can always be transferred back. But given his relative stability and family's desire to bring him home and agreement by his MD, home care with 24 hour Skilled Nursing is medically necessary. The health plan did not act reasonably in the best interest of the patient.

The carrier's denial of continuation of coverage for 168 hours per week of Private Duty Nursing Licensed Practical Nurse (LPN) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient  has a past medical history significant for heart disease, hypertension, hypothyroidism, hyperlipidemia, neuropathy and a peripheral ulcer.The patient is currently approved for 45.5 hours a week, and requests 56 hours a week of personal care aide assistance.The health plans determination is upheld in whole. The requested health service/treatment of Personal Care Aide Level 2: 8 hours per day-7days per week-for a total of 56 hours per week is not medically necessary for this patient.The assessment was reviewed along with the patient's notes including the Uniform Assessment System, two  separate occasions. At that time is noted that the patient required a total of 6 hours a day 7 days a week for a total of 42 hours a week. Currently the patient is approved for 6.5 hours a day 7 days a week for 45.5 hours a week. Looking at the patient's medical condition along with the evaluation, it is noted patient has a peripheral leg ulcer which causes pain in the  leg and decreases  ambulation. The other tasks such as meal preparation, medication management and ordinary housework have not changed. The patient did have some decreased functioning with bed mobility bathing and toilet transfer. Additional service hours were noted to help with these Activities of daily living (ADLs). Accordingly, the amount of time which was allotted for these ADLs and Instrumental Activities of Daily Living (IADLs) is sufficient to meet these needs. Additional service hours are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Aphasia following cerebral infarction, dysphagia following cerebral infarction, ataxia following cerebral dysfunction

Treatment:  Level ll skilled nursing facility stay beyond a specified date

The insurer denied coverage level ll skilled nursing facility stay beyond a specified date. The denial was reversed.

This patient is a male with current diagnoses including aphasia following cerebral infarction, dysphagia following cerebral infarction, ataxia following cerebral dysfunction, malignant neoplasm of prostate, secondary malignant neoplasm of bone, other primary thrombophilia, thyroid disease, non-ST elevated myocardial infarction, non-rheumatic mitral valve disorder, unspecified, acute embolism, and thrombosis of unspecified deep veins of unspecified lower extremity, other lack of coordination, essential, primary hypertension, constipation unspecified, and hyperlipidemia unspecified.  The patient underwent hospitalization due to a cerebrovascular accident (CVA).  The patient had presenting symptoms including non-sensical speaking, aphasia, and loss of recent memory and balance impairments.  The patient was transferred for treatment with physical therapy, Occupational Therapy, and Speech therapy.  The records supported that prior to admission the patient had been independent with ambulation and with driving.  The recommendation was made for physical therapy services 7 times a week for 3 weeks.  The records indicated discharge planning occurred.  On discharge, the patient was independent with bed mobility, transfers, and could ambulate 150 feet and on stairs.  The patient was to undergo physical therapy/occupational therapy/speech therapy through a home health agency per the treatment plan summary for discharge to ensure a safe transition.

The healthcare plan did not act reasonably in the best interest of the patient.  The level II skilled nursing facility stay beyond a specified date is considered medically necessary for this patient. 

A skilled nursing facility was still medically necessary.  Again, patient lived alone without support.  He still had significant deficits with both cognition and needed supervision for transfers as noted in the therapy note on a specified date.  Notes state "floor to bed transfers with supervision" and that the patient still has "difficulty manipulating objects."  Also, the discharge note stated "discharge with family and community support," which he did not have at the time.

The patient met InterQual criteria as he was receiving and needed continued monitoring.  He was not clinically stable for safe discharge for the reasons noted above.

Based on the above, the medical necessity for the level II skilled nursing facility stay beyond a specified date is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for a stab wound in the abdomen and chronic marijuana use who presented to the emergency department with complaints of recurrent episodes of vomiting and generalized abdominal pain that was more pronounced in the right upper quadrant. The symptoms started on the day of admission and never had similar symptoms in the past. At the time of the initial evaluation, the patient denied any fever, diarrhea, chest pain, shortness of breath, or urinary problems. The patient used marijuana regularly and his last use was on the day that preceded the day of admission. At the time of the initial physical exam, the patient appeared to be afebrile, his blood pressure was 155/80, pulse rate 64, respiratory rate 18, and oxygen saturation 98% on room air. The abdomen was soft, with generalized tenderness more pronounced in the right upper quadrant, bowel sounds were present. The patient was admitted.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented to the hospital with acute onset of abdominal pain, nausea, and several episodes of non-bloody, nonbilious vomiting. The initial evaluation was suggestive of possible mild colitis, therefore, the patient was admitted to the hospital and treated with intravenous fluids, pain medications, and antibiotics. Mild gastritis was also suspected, and the patient received treatment with Pepcid. At the same time, the results of the physical exam, laboratory studies, and diagnostic tests did not reveal any dangerous medical conditions potentially requiring admission at an acute inpatient level of care. This patient did not have peritoneal signs on physical exam, severe electrolyte abnormalities, or kidney failure reflecting possible dehydration due to vomiting. There was no evidence of acute pancreatitis based on the laboratory evaluation (normal lipase) or any liver or gallbladder problems based on the computed tomography (CT) scan of the abdomen.
Taking into consideration these facts, observation was warranted to ensure hemodynamic stability, to ensure improving oral intake, as well as to ensure a resolution of the patient's gastrointestinal symptoms. At the same time, the severity of the patient's condition and the complexity of the services provided did not justify admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia, COPD
Treatment: Inpatient admission

The inpatient admission was not medically necessary.  

This patient was evaluated in the emergency department for increased shortness of breath and lower extremity edema.  She had severe anemia and was treated with blood transfusion.  Hemoglobin improved and she had improved shortness of breath.  She was noted to have COPD with a baseline oxygen requirement of five liters, which did not worsen at all during her hospital stay.  COPD was treated with inhalers and she was treated with Lasix for lower extremity edema.  She did not undergo any additional evaluation for anemia or weight loss because she consistently refused such evaluation.  Treatment with Lasix and inhalers did not require acute care inpatient admission.  Blood transfusion also did not require acute care inpatient admission.  Review of records finds no intervention requiring acute care inpatient admission.  She had no worsening hypoxia, no acute infection and no hemodynamic instability.  There was also no ongoing clinically apparent hemorrhage.  Hemoglobin was noted to be falling but in the absence of acute hemorrhage, admission was not required for that reason.
Appeal type: Medical necessity
Decision: Upheld

The records indicate that the patient with weakness in the left leg. The patient reportedly had a stroke two years previously as a complication of the patient's sickle-cell anemia.
It was noted the patient received 31 physical therapy sessions. The physical therapy evaluation was compared and noted to be virtually identical indicating the patient could exercise for 15 to 20 minutes and had decreased endurance. The health plans determination of medical necessity is upheld in whole. Therapy is only medically necessary when the therapeutic benefit has not been reached and the therapeutic interventions are for conditions that require the unique knowledge, skills and judgment of a qualified practitioner, and there is reasonable expectation that the therapeutic interventions, based on a beneficiary's rehabilitation potential, will result in objective/measurable functional outcomes within a reasonable and predictable amount of time. The patient does not meet these criteria for medical necessity.