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

Diagnosis: diverticulitis
Treatment: Long Term Acute Care Hospital 
The insurer denied continued Long Term Acute Care Hospital stay. 
The health plan's determination is upheld. 

The patient is a male who is admitted to the hospital initially secondary to diverticulitis. He had multiple complications including cardiac arrest resulting in ventilator-dependent respiratory failure. He was initially admitted to the hospital and subsequently transferred to LTAC (long term acute care).

The Continued Hospital Stay in Long Term Acute Care Hospital (LTACH)  is not medically necessary for this patient.
The patient was initially admitted to the hospital secondary to acute diverticulitis. He suffered multiple complications status post-surgical resection. Complications included sepsis, small bowel obstruction and colostomy. He had a cardiac arrest which led to intubation, failed extubation and need for tracheotomy and percutaneous endoscopic gastrostomy (PEG) tube. He was discharged from acute care hospital and admitted to LTAC.
By the day in question, the patient was weaned off the ventilator. The patient was decannulated There were no other services being provided that could not have been performed at a lower level of care. Such services include complex wound care or other acute intravenous antibiotic treatment. He did have continued management of PEG tube along with Jackson-Pratt (JP) drain. He did have some electrolyte and fluid abnormalities treated with hypertonic saline and Kayexalate.
The patient's medical status is stabilized. The patient was weaned from the ventilator and decannulated. He was started on a trial of oral liquids. His vital signs are stable. He had significant weakness from his underlying medical condition requiring physical and occupational therapy. Typically, a condition such as generalized weakness secondary to medical comorbidities can be treated at a lower level of care such as skilled care. It was not medically necessary for the patient to stay in the LTAC for fluid/electrolyte abnormalities management, once his other conditions have stabilized.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epileptic Spasms.
Treatment: SleepSafe Bed and SleepSafe Pads.
The insurer denied the SleepSafe Bed and SleepSafe Pads.
The denial is overturned. 

The patient is a male child with medical history significant for Lennox-Gastaut syndrome with intractable seizures, infantile spasms, epileptic encephalopathy, gastroesophageal reflux disease and dysphagia status post gastrostomy tube placement, Sandifer syndrome with spasticity and hypotonia, laryngomalacia and apnea status post recent tracheostomy tube placement, failure to thrive, and global developmental delay. He experiences frequent breakthrough seizures. He requires frequent suctioning to maintain a patent airway. Because of his oropharyngeal hypotonia and gastroesophageal reflux, he is at significant risk of aspiration. He has increased tone in his extremities leading to involuntary spastic movements. He is fully dependent upon caregivers for all activities of daily living. He currently sleeps in a pack-n-play, spending most of his time there with a variety of pillows and blankets to facilitate appropriate positioning. He is outgrowing this sleeping solution, and the positioning attempts are no longer effective.

Yes, the proposed SleepSafe Bed with SleepSafe Pads are medically necessary for this child.

A SleepSafe Bed with SleepSafe Pads as a safe sleeping environment is medically necessary and appropriate for this fragile young male child for multiple reasons. First of all, he has outgrown his Pack-N-Play, the sleeping solution that the family has been using up to this point. He can no longer be appropriately positioned with pillows and blankets to prevent aspiration. It is impossible for his mother to reach him while he is lying down to adequately suction his tracheostomy tube and clear his airway. Second, a standard hospital bed poses risk of entrapment because of the side rails. He does not have control of his movements, with extremity spasticity and uncontrolled dystonic movements. He is a risk for entrapment without the ability to free himself. Third, his myriad medical problems place him at risk. He has poorly controlled seizures that increase likelihood of entrapment and injury. Challenges in positioning, completing activities of daily living, and preventing complications all increase risk of morbidity. He suffers from gastroesophageal reflux disease and is at risk for aspiration as a result; this is compounded by his spasticity and seizure disorder, thus making a bed that is adjustable essential to maintain his safety. The requested SleepSafe Bed with SleepSafe Pads is thus medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious diarrhea. 
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a male with a medical history of atrial fibrillation (on Coumadin and digoxin), multiple sclerosis, chronic kidney disease and rheumatoid arthritis, who presented to the Emergency Department (ED) with complaints of diarrhea and fever. In the ED, the patient was found to be febrile with temperature of 101.1 Fahrenheit, and have elevated lactic acid and creatinine. The patient's stool specimen was positive for Enteroinvasive Escherichia coli (EIEC)/Shigella and required intravenous (IV) antibiotic and fluids. The patient was also on anticoagulation with Coumadin for his atrial fibrillation that required titration and monitoring to international normalized ratio (INR) goal of 2.5-3.5. 

As per literature review, the evaluation of patients with diarrhea should include a careful history to determine the duration of symptoms and the frequency and characteristics of the stool. The focus is on extracellular volume depletion (e.g., decreased skin turgor, orthostatic hypotension); fever and peritoneal signs may be clues to infection with an invasive enteric pathogen. Severe illness can be suggested by one or more of the following, but is not limited to:

1) Profuse watery diarrhea with signs of hypovolemia, 2) Passage of many small volume stools containing blood and mucus, 3) Bloody diarrhea, 4) Temperature greater than or equal to 38.5o Celsius (101.3o Fahrenheit), 5) Passage of 6 or more unformed stools per 24 hours or duration of illness more than 48 hours, 6) Severe abdominal pain, 7) Hospitalized patients or recent use of antibiotics, 8) Diarrhea in the elderly or the immunocompromised, and 9) Systemic illness with diarrhea, especially in pregnant women (in which case listeriosis should be suspected).

Based on the review of the medical record, inpatient admission was medically necessary for this patient. This patient had infectious diarrhea that required IV antibiotics and was on anticoagulation medication that required close monitoring and titration to INR goal of 2.5-3.5. The patient could not have been safely and effectively managed at a less intensive level of care, such as observational level of care or outpatient care. 

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

The medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries - Laceration
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary.  
The reviewer has overturned in whole the health plan determination of medical necessity.

The patient is a pediatric patient who presented with a fall from bed, sustained head injury, and laceration above the left eyebrow. He was a level II activation. He was admitted to the Pediatric Intensive Care Unit (PICU) for concern for life threatening injury. There was no loss of consciousness (LOC), positive lethargy initially, then crying. He was discharged the next day. He did have a low bicarbonate level and was admitted for every (q) 1 hour neurological (neuro) checks.

The requested inpatient stay was medically necessary for this patient, given the patient's age, neurological findings, and evidence of substantial trauma given the head laceration (3 centimeters). The admission falls within the Milliman Care Guidelines, Neurology criteria. In children, manifestations of severe head injury can take 24 hours to "blossom." Therefore, careful observation with neuro checks is warranted and avoiding computed tomography scan is important. According to the validated tool in Pediatric Emergency Care Applied Research Network (PECARN), this patient would fall into the hospital observation status. [1]

In this instance, with the substantial laceration, an inpatient level of care for observation for q 1 hour nursing was appropriate. An observation or lower level of care is not conducive to frequent vital sign/neurologic exam checks. "Observation status" means limited intervention is needed. This child required an observation period as an inpatient for neurological checks. That is different than observation status/level of care. Pediatric acute traumatic epidural hematomas frequently present with subtle clinical signs, including a normal Glasgow Coma Scale score almost half of the time. They occur in 3% of head injuries in children and carry a 2% mortality. In children, physical examination findings of trauma to the scalp or skull may be even more important than classic symptoms or neurological examination. Irrespective of asymptomatic presentation, threshold for an observation period (meaning with frequent neuro exams) should be low after head injuries in children. [4]

To be clear, this patient needed an inpatient admission for frequent neurological monitoring with the potential for lifesaving emergent intervention.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the Emergency Department with a two day history of worsening perianal pain with associated fever and chills. Evaluation in the Emergency Department documented the patient to be febrile (temperature - 103.1), tachycardic (110's) and hypotensive (90's/50's). Physical exam notes swelling, induration and tenderness at the anal verge in the left lateral position. White blood cell (WBC) was elevated at 16.2. Computed tomography (CT) scan was confirmatory of a two by four by eight centimeter (cm) perianal abscess.

The patient's past history is pertinent for multiple perianal abscesses requiring drainage with the last being about two years prior.

The patient was treated in the Emergency Department with intravenous (IV) fluids and antibiotics and was admitted to acute inpatient status where he underwent uneventful surgical drainage of a left sided perianal abscess that afternoon. The post-procedure Surgical Note that evening notes the patient to be afebrile, hemodynamically stable and resting comfortably.

The Surgical Progress note documents a temperature of 99, blood pressure of 93/60 and pulse of 92, with a plan to advance to a regular diet, discontinue IV fluids and convert to oral antibiotics. The Nursing notes document the patient was afebrile, ambulating independently, tolerating a regular diet and without distress.

No, the proposed inpatient admission was not medically necessary.

The patient's condition and treatment rendered following surgery did not rise to the level of acute inpatient care.

The medical record documents that the patient remained afebrile and was hemodynamically stable with no untoward events following surgery. He was noted to be on a regular diet, ambulating without aid and without distress on the morning following surgery. He declined use of a sitz bath when offered. There are no Medical Progress Notes contained within the medical record between the one the morning following surgery and the Discharge Order and Summary, indicating that there was no change in the patient's condition and no interventions were required in that time frame. The Nursing Notes and Flow Sheets of the same time interval are confirmatory of a stable and uneventful post-procedural stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety, cancer, CAD, depression, heart failure and dementia.
Treatment: Increase of Personal Care Worker services 7 days per week, 12 hours per day; 84 hours per week.
The insurer denied the increase of Personal Care Worker services 7 days per week, 12 hours per day; 84 hours per week.
The denial is upheld. 

The patient is a female with conditions including anxiety, cancer, CAD (coronary artery disease), depression, heart failure and dementia.  The patient is requesting an increase in PCW (personal care worker) services from 28 to 84 hours per week.

The patient's assessment showed the following: minimally impaired cognition; maximal assistance with meal prep and shopping; total dependence with housework; extensive assistance with managing finances and medications, phone use, stairs, transportation, bathing, and LB (lower body) dressing; limited assistance with personal hygiene, UB (upper body) dressing, locomotion, toileting, and bed mobility.  The patient lives alone.  The patient's son notes that the patient has a history of frequent falls due to weakness, but the patient declined PT (physical therapy).

No, the increase of Personal Care Worker services 7 days per week, 12 hours per day; 84 hours per week is not medically necessary.

Medically necessary services are typically the following:

1) Safe, 2) Effective, 3) Generally accepted national standard of medical practice, 4) Not provided primarily for convenience of the patient or the practitioner, and 5) The least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested increase of Personal Care Worker Services 7 days per week, 12 hours per day; 84 hours per week is not medically necessary, because it is not in accordance with generally accepted national standard of medical practice for this patient's scenario.

Personal Care Worker services provide hands-on assistance to individuals to include the following: assistance with ADLs (activities of daily living); health maintenance activities; and routine support services.  This patient requires assistance as noted above.  Assessment by PT for fall risk was declined.  The patient requires limited assistance with ambulation, transfers and toileting.  The assessment does not support the medical necessity for Personal Assistance service for a total of 84 hours per week.  The approved 28 hours per week are sufficient to provide assistance with ADLs that include meal prep, housework, medications, shopping, transportation, and dressing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Enteritis and Urinary tract infection.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld. 

This is a male patient with a history of alcoholic pancreatitis, who presented to the Emergency Department (ED) with abdominal pain.  On presentation, the patient was afebrile, and his vital signs were stable.  On examination, there was no abdominal rebound or guarding.  Laboratory findings revealed that there was no leukocytosis.  The patient's hemoglobin was elevated, but his renal function was normal.  The patient's computed tomography (CT) scan revealed enteritis.  The patient was treated with intravenous (IV) hydration and antibiotics.  The patient also received antibiotics that would cover a urinary tract infection (UTI).

Clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection, such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, and a persistent severe electrolyte abnormality.  In this case, the patient did not have these conditions.

Based on the review of the medical record and literature, the inpatient hospital admission was not medically necessary for this patient.  This patient had enteritis.  However, intravenous (IV) hydration could have been given in the Emergency Room (ER) with observation status.  The patient's enteritis and urinary tract infection (UTI) could have then been treated with a course of oral antibiotics as an outpatient.  The patient did not meet the Milliman Care Guidelines (MCG) criteria for an admission for enteritis.  

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

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

Diagnosis: Dental Problems (overjet, open bite, Class I malocclusion, and anterior crowding).

Treatment: Braces D8080.

The insurer denied coverage for braces D8080.

The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including overjet, open bite, Class I malocclusion, and anterior crowding and has recommended orthodontics.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.  

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore, medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report modeled after Handicapping Labio-Lingual Deviation (HLD) index.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 8 points on the Handicapping Labio-Lingual Deviation (HLD) index (i.e., 4 for overjet, 2 for overbite, 2 for labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

The coverage of braces D8080 comprehensive orthodontic treatment of the adolescent dentition is not considered medically necessary for this patient.

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

The carrier's denial of coverage for braces D8080 should be upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Preconception genetic counseling and testing.
Treatment: Carrier Screen Testing.

The insurer denied coverage for Carrier Screen Testing.
The denial is overturned. 

This is a female patient whose husband had a maternal first cousin with cystic fibrosis. They inquired about carrier screening as part of a preconception counseling visit. A carrier screening panel was ordered.

This patient meets national guidelines for carrier screening.  According to the American College of Obstetricians and Gynecologists (ACOG), "All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis and spinal muscular atrophy, as well as a complete blood count and screening for thalassemias and hemoglobinopathies." Also, "Information about genetic carrier screening should be provided to every pregnant woman.  After counseling, a patient may decline any or all screening."

The ACOG also states, "Ethnic-specific, panethnic, and expanded carrier screening are acceptable strategies for prepregnancy and prenatal carrier screening. Each obstetrician-gynecologist or other health care provider or practice should establish a standard approach that is consistently offered to and discussed with each patient, ideally before pregnancy. After counseling, a patient may decline any or all carrier screening." This advocates for such a panel as she had.      

This meets the approval of the ACOG and the American Society of Reproductive Medicine (ASRM). ASRM states, "Preimplantation genetic testing for monogenic disease (PGT-M) for adult-onset conditions is ethically justifiable when the conditions are serious and when there are no known interventions for the conditions, or the available interventions are either inadequately effective or are perceived to be significantly burdensome."     

This patient is a good candidate for the Carrier Screen Testing.

She is a good candidate, because as per the ACOG "Prepregnancy carrier screening is ideal because it provides patients with the opportunity to learn their carrier status and allows reproductive partners to discover if they are both carriers of the same condition before pregnancy. Patients then can consider whether or not to conceive and whether to use advanced reproductive technologies such as preimplantation genetic diagnosis or donor gametes."     

The Carrier Screen Testing is the best available treatment for this patient at this time.

This type of screening, universal or expanded carrier screening has become the gold standard and optimal type of screening in the preconception period. The screening ordered accomplishes this.

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

The carrier's denial of the Carrier Screen Testing should be overturned.