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

Diagnosis: Atrial Fibrillation
Treatment: LifeVest wearable cardioverter defibrillator
The insurer denied the LifeVest wearable cardioverter defibrillator.
The determination is overturned.

The patient was admitted to the hospital with atrial fibrillation and congestive heart failure. An echocardiogram showed a left ventricular ejection fraction of 15-20%. A transesophageal echocardiogram showed no evidence of a left atrial thrombus and the patient was electrically cardioverted to sinus rhythm. His cardiomyopathy was deemed to be nonischemic. He was treated with amiodarone and guideline-directed medical therapy for congestive heart failure. When seen in follow-up, he remained in sinus rhythm. A LifeVest wearable cardioverter defibrillator (WCD) was prescribed. The medical necessity for the WCD for three months is at issue.
The LifeVest wearable cardioverter defibrillator was medically necessary.
Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this patient, with nonischemic cardiomyopathy, and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with time and/or treatment, it is recommended that device implantation be delayed for at least 90 days following the initial diagnosis of nonischemic cardiomyopathy. If, after 90 days of optimal medical therapy, the left ventricular ejection fraction (LVEF) remains less than or equal to 35%, ICD implantation is then recommended. However, subset analyses of patients from the large multi-center randomized DEFINITE trial evaluating the use of ICDs in nonischemic cardiomyopathy for the primary prevention of sudden cardiac death have shown that even patients with recently diagnosed cardiomyopathy are at risk for serious ventricular arrhythmias. Accordingly, many physicians prescribe the LifeVest WCD as a "bridge" to potential ICD implantation in newly diagnosed patients. The efficacy of the WCD in detecting and terminating serious ventricular arrhythmias compares favorably to that of the implanted device. The WEARIT-II Registry was a prospective registry that enrolled 2000 patients with cardiomyopathy who were treated with the WCD. 927 (46%) had nonischemic cardiomyopathy. The median WCD wear time was 90 day. The rate of sustained ventricular tachyarrhythmias that were successfully treated with the WCD by 3 months was 1% among nonischemic patients. Thus, the risk of sudden death during this relatively short time period was not insignificant and the WCD successfully mitigated this risk. The medical literature supports the use of the WCD in this situation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skin Disorders. 
Treatment:  Inpatient Hospital. 

The insurer denied full hospital admission.  The denial is upheld in whole.

The patient is a female with past medical history of hypertension, asthma, lymphoma in remission, obstructive sleep apnea, osteoporosis, lymphedema, and morbid obesity who presented to the emergency department with bilateral leg weeping and swelling.
On presentation, she was afebrile with the rest of her vitals also unremarkable.  Exam otherwise noted bilateral lymphedema of the lower extremities with circumferential erythema of the bilateral calves, chronic venous stasis changes and crusting lesions with minimal serous fluid weeping from the wound.  Labs resulted with white blood cell (WBC) 9.2, hemoglobin (HGB) 12.1, Platelets 225, basic metabolic panel within normal limits with glucose 121, and lactic acid of 2.4.  Venous duplex ultrasound of the lower extremities was attempted but was of limited value without full visualization of her lower extremity veins secondary to morbid obesity.  She was initiated on cefazolin and subsequently brought into the hospital with concerns for stasis dermatitis lymphedema with notes stating she likely did not have cellulitis given normal WBC with no purulence or tenderness of her legs.  Plans were for leg elevation, monitoring off antibiotics for 24 hours, starting triamcinolone cream, mupirocin and ace wraps, and referral of the patient to lymphedema clinic.

She remained hemodynamically stable.  Exam noted an area in the right posterior calf without pus that was warm but not tender.  Infectious disease saw the patient with assessment that she had venous stasis dermatitis and with recommendation to continue oral antibiotics with Keflex for 7 days and to refer the patient to lymphedema clinic.  She was seen by vascular surgery who noted that she had a shallow ulcer to her right posterior calf without leukocytosis or fever and with recommendation to elevate legs and proceed with compression wraps.  The patient was discharged.

The health plan's determination is upheld in whole.

This is a patient with morbid obesity and lymphedema who presented to the hospital with concerns for lymphedema with chronic venous stasis without clear evidence of cellulitis per notes, with plan of care consisting of leg elevation, leg wraps, and oral antibiotics.  She was afebrile, without leukocytosis, and with infectious disease recommending oral antibiotics only without intravenous (IV) antibiotics needed.  She otherwise had no unstable medical issues, and it is noted that the treatment of leg elevation and leg wraps can usually be safely accomplished in a lower level of care setting.  It was reasonable to monitor the patient in the hospital, but inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/musculoskeletal
Orthotics (Shoe Inserts)

Diagnosis: plantar fasciitis
Treatment: custom foot orthotics 
The insurer denied the custom foot orthotics. The health plan's determination is overturned. 

The patient is a female with plantar fasciitis, ankle equinus and valgus foot deformity. The patient has had pain for over 3 months. She has attempted conservative treatment which has included supportive shoes, pre-fabricated orthotics, stretching and activity modification. A request has been made for custom functional orthotics. 

The requested custom foot orthotics are medically necessary for this patient. Custom foot orthotics are a standard modality utilized in the treatment of plantar fasciitis. In addition, the patient had already attempted multiple other treatment modalities which were not successful. A meta-analysis by Lee et al showed that the use of foot orthoses in patients with plantar fasciitis appears to be associated with reduced pain and increased function. Stuber and Kristmason, in a narrative review of randomized controlled trials (RCTs), demonstrated several studies that showed custom-made orthotics were more beneficial than over-the-counter devices.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied the Testosterone 1% transdermal gel. The denial is overturned in whole. 

The patient is a male with a diagnosis of symptomatic hypogonadism and low testosterone levels. The patient has had success with Androgel and has a history of adverse reactions to other forms of testosterone therapy. 

The subject under review is the medical necessity for the Testosterone 1% Transdermal Gel. 

The health plan's determination is overturned in whole. 

This is a patient with a diagnosis of symptomatic hypogonadism with several documented testosterone level less than 300 nanograms per deciliter (ng/dl), with the most recent value as low as 173 ng/dl (normal range 193-740). He has previously had success with use of Androgel and has a history of severe adverse reactions to other forms of testosterone replacement. As  documented in the urologist's notes, untreated hypogonadism is associated with decreased energy levels, decreased mental libido, sarcopenia and osteoporosis. Therefore, treatment with Testosterone 1% Transdermal (Androgel) is necessary for this patient to prevent adverse health consequences from untreated hypogonadism. The patient has had severe adverse reactions to other forms of testosterone replace, so Testosterone 1% transdermal gel (Androgel) is medically necessary and in the best interest of this patient. 

The request for Testosterone 1% transdermal gel in this case is medically necessary according to the standard of care, professional guidelines per American Urological Association (AUA) guidelines on testosterone deficiency (evaluation and management). The patient has more than 2 documentation that shows his Testosterone is less than 300 ng/dl and is symptomatic from this condition.  Per AUA guidelines, testosterone replacement is recommended. Guidelines also states alkylated oral testosterone should not be given. Transdermal form such as in this case was the proper form of replacement, as other commercially available products caused the patient to have side effects, as documented by the treating provider.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: rheumatoid arthritis
Treatment: Personal Care Aide (PCA) Level 2 Services
The insurer denied Personal Care Aide (PCA) Level 2 Services: 13 Hours per Day, 7 Days per Week (Total of 91 Hours per Week). The health plan's determination is upheld.

The patient is a female with multiple past medical history including rheumatoid arthritis, hypertension, diabetes, chronic MAI, dementia and generalized weakness.

The Personal Care Aide (PCA) Level 2 Services: 13 Hours per Day, 7 Days per Week (Total of 91 Hours per Week) is not medically necessary for this patient. The patient has multiple medical problems most notably rheumatoid arthritis, chronic pain, heart disease and generalized ability. She has a poor functional status requiring level to services for most if not all activities of daily living (ADL) and Instrumental activities of daily living (IADL).
It is noted that the patient was able to walk 15-149 feet at one time without sitting down and did not use a wheelchair. She was admitted to the hospital. She was subsequently discharged to rehabilitation center. She was noted to have increased pain along with shortness of breath which was relieved with nasal oxygen at 2 L. Shortness of breath was absent at rest.
It was noted that the patient uses incontinent supplies such as pull-ups. The patient requires assistance with most activities of daily living.
Evaluation was done after the patient was hospitalized, and it is unclear if this was done while the patient was in a rehab center or at home setting. Either way, functionally she was very similar to previous evaluation.
Specifically absent on the Uniform Assessment System (UAS) was any documented need for nocturnal hours such as bedsores or need for frequent repositioning at night.
The UAS State of New York showed most of the patient's ability to perform functional status seems since previous evaluation. The patient's abilities to dress upper and lower body, personal hygiene, bed mobility, transferring, toilet use, eating, meal preparation ordinary housework stayed the same. The UAS did not support the need for nighttime hours.
The patient was able to transfer on and off the toilet with assistance. An Evaluation noted that the patient's endurance is weak, but ambulation is good. There did not appear to be a significant functional decline when evaluating both reports. The patient requires significant assistance with ADLs and IADLs. The hours allotted by the health plan are sufficient to meet these needs as documented through the nursing reports. There were no additional documented needs which would require additional services or nocturnal hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Disorder.
Treatment:  Dental Implant Tooth #19.

The insurer denied the Dental Implant for Tooth #19.  The determination is overturned.

The patient presented to the oral surgeon for dental implant placement at the site of missing tooth #19.  The implant was performed.  At issue is the medical necessity of the dental implant for tooth # 19.

It is reasonable to restore a patient's dentition to first molar occlusion, which this procedure did.  It is considered a fairly predicable surgery with a high success rates with a variety of implant systems and applications (89 to 98 percent).  Replacement of missing teeth with dental implants is common practice in dentistry.  Loss of teeth without replacement may have several adverse outcomes, including among others masticatory dysfunction, speech and articulation errors, and pain secondary to chronic mucosal irritation and ulceration.  Since there is no tooth posterior to tooth #19, there is only a removable option, which is a partial denture, which is considered less ideal because it is removable versus fixed (which an implant is) and also because it is more suited to replacement of multiple teeth versus just one.  Therefore, the dental implant for tooth number 19 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who has a history of Crohn's disease. The patient has a history of ileal resection with ileostomy. The patient had recently undergone care for rectal bleeding from an ileal anastomotic ulcer.  The patient then presented with the complaint of rectal bleeding with bright red blood to the hospital which has filed the appeal. 

The patient presented with normal vital signs, hemodynamic stability, and a hemoglobin of 12.9. Repeat values showed a hemoglobin of 10.2. The patient received a blood transfusion. He then passed a non-bloody bowel movement. The patient underwent a colonoscopy which found ulcerated mucosa and bleeding at the ileal anastomosis. This was treated endoscopically with placement of clips. There was no further bleeding evidenced. The patient was discharged.

No, the proposed inpatient admission was not medically necessary.

The patient received care that was medically appropriate in its entirety; however, the level at which the care was rendered was not medically necessary. The patient presented with hemodynamic stability. He underwent a definitive colonoscopy with direct treatment of the bleeding site. Once treated there was no further bleeding. The patient did receive a blood transfusion; however, the patient was hemodynamically stable the entirety of the episode of care. The patient did not require a full, acute hospitalization as the care rendered could have been performed at a lower level of care in its entirety.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a female with a history of alcohol use disorder and alcohol induced seizure who presented after a seizure.  She had been binge drinking.  

Vital signs (VS) were as follows: 99.1, 65, 17, 134/93, and 100%.  Exam was remarkable for moderate tremulousness and left lower rib discomfort.  Clinical Institute Withdrawal Assessment (CIWA) was 15 down to four.  Labs revealed the following: white blood cell (WBC) 3.7, hemoglobin/hematocrit (H/H) 12.1/35.4, and platelets (PLT) 186. Head computed tomography (CT) showed no acute disease (NAD).  Cervical (C) spine CT showed NAD.  Electrocardiogram (EKG) revealed sinus bradycardia.  

The patient was admitted.  Plan of care included CIWA protocol.  The patient was complaining of headache.  She was tolerating by mouth (PO).  CIWA was eight.  She was considered for Librium taper.  Plan for right upper quadrant (RUQ) ultrasound (US) for elevated bilirubin.  he patient had a posterior headache and left upper quadrant discomfort, tongue fasciculations and mild tremulousness.  CIWA was nine.  The patient was cleared for discharge.

No, the proposed inpatient admission was not medically necessary.

This patient was admitted after presenting with an alcohol-induced seizure.  The patient did not have active comorbid conditions.  The patient was hemodynamically stable and afebrile.  She did not have tachycardia or arrhythmia.  She did not have persistent vomiting, delirium, seizures, or gross tremor.  Labs were unremarkable.  The patient was admitted with plan for CIWA protocol.  The patient remained hemodynamically stable. She was not scoring high on CIWA protocol.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  She did not have symptoms that required an acute inpatient level of care.  She had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted canine
Treatment: Braces and monthly visits
The insurer denied the braces and monthly visits.
The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits and monthly visits.

Yes, the proposed treatment with braces and monthly visits is medically necessary. 

The patient's lower left canine is impacted (i.e. stuck in the bone) and there is no room for it to erupt properly. Orthodontic treatment is needed to create space for this tooth to erupt. An impacted permanent anterior tooth, where extraction is not indicated is an automatic qualifier, according to the handicapping index scale. This case has medical necessity to correct this problem.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a pregnant female who presented to the hospital at 30-3/7 weeks gestation. The patient was noted to be pregnant with twins. She was noted to have a referral from the office for admission for steroids and magnesium given preterm contractions. The patient had no leakage of fluid from the vagina, no vaginal bleeding and no pain. She reported no decreased fetal movement. Her review of systems was also negative and specifically was negative for abdominal pain, nausea or vomiting, urinary frequency, anxiety, or depression. The patient had no vaginal bleeding or vaginal discharge. Her prior history was noted for no prior obstetrical history. She was admitted.

Based upon a review of the medical records, the recommendations of the American College of Obstetrics and Gynecology (ACOG) and the MCG Guideline entitled "Preterm Labor, Threatened", the inpatient stay was not medically necessary. In this case, the patient was noted to have a twin gestation at 30 3/7 weeks gestation with threatened preterm labor. There was a closed cervical exam on admission by the physician. A fetal fibronectin test was also negative. However, given preterm contractions (even in the setting of a closed cervix and negative fetal fibronectin), a plan was made for ultrasound, magnesium and steroids. The ultrasound and monitoring were reported as normal and reassuring with a twin gestation that noted a closed cervical length of 1.2 cm. The patient completed a 24 hour window of magnesium sulfate without complications for completion of steroids and neuroprotection. There was completion of two doses of betamethasone for fetal lung maturity. The patient had a trial of tocolysis that was successful and without complications with the magnesium sulfate. In this case, the care rendered would have been appropriate at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abscess.
Treatment:  Inpatient Admission.

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

The patient is a female with a past medical history of hypertension, diabetes mellitus, and hyperlipidemia who presented to the Emergency Department (ED) with complaint of right abdominal/hip abscess following a spider bite.  The patient's vitals on presentation included: Temperature 98.2 F, Blood Pressure 147/76, Pulse 126, Respiratory Rate 20, Oxygen (O2) Saturation 99% on room air.  The patient's laboratory results included the following: white blood cell (WBC) count of 21.79, hemoglobin of 12, hematocrit of 39, creatinine of 1.5, glucose of145, and lactate of 4.1.  The patient was admitted for cellulitis/abscess of the right flank area.  She received intravenous (IV) antibiotics; vancomycin and Zosyn.  Surgery was consulted and an incision and drainage (I&D) was performed.  The patient's wound culture grew methicillin-resistant Staphylococcus aureus (MRSA).  The patient received wound care.  The patient remained afebrile, hemodynamically stable and clinically improved.  The patient was discharged to continue outpatient management on oral antibiotics.

According to documentation, the patient presented with a right flank abscess.  Although, the patient was afebrile, the patient had been on oral antibiotics prior to admission.  The patient was tachycardic with heart rate of 126, and had multiple laboratory abnormalities including elevated WBC count of 21.79, glucose of 145, lactate of 4.1 and creatinine of 1.5.  Based on these clinical findings in a patient with co-morbid conditions and documented failure of outpatient management, hospital admission was medically necessary for administration of intravenous (IV) antibiotics and surgical intervention.  

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

Based on the above, the medical necessity for the acute inpatient stay is substantiated.  The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Non-ischemic Cardiomyopathy, Congestive Heart Failure.
Treatment:  Inpatient admission.
The insurer is denied coverage for inpatient admission.  The denial is upheld. 

The patient was a male with a history of non-ischemic cardiomyopathy, congestive heart failure, hypertension, hyperlipidemia, and status post substance abuse.  He presented for a scheduled elective implantation of a transvenous implantable cardioverter defibrillator (ICD).  The patient's pre-operative ejection fraction was 25%.  There were no complications during the procedure. The patient was admitted to telemetry following the procedure.  Chest radiography showed no pneumothorax.  He remained stable with no telemetry events or site complications and he was then discharged.

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

Inpatient admission status was not medically necessary, per MCG Guidelines for
Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion.  For
uncomplicated pacemaker and/or ICD implantation, this is considered an elective outpatient procedure, with up to 1 night of observational status hospital monitoring permitted.  There were no post-operative complications, such as bleeding or infection, nor any clinical or hemodynamic instability.  There was no evidence of procedurally-related pneumothorax.  The hospital should not be reimbursed at the inpatient rate, but rather at the ambulatory surgery rate.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.