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

Diagnosis: Abdominal Pain, Nausea and Vomiting (status post laparoscopic cholecystectomy)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female. She was admitted for acute cholecystitis on her second ER (emergency room) presentation. She had nausea, vomiting and abdominal pain.

The patient's PE (physical examination) showed a positive Murphy's sign, which is consistent with acute cholecystitis. Her WBC (white blood cells) were elevated, along with elevated immature granulocytes. She was admitted for IV (intravenous) hydration, IV (intravenous) antibiotics and emergency surgery. During her stay, she required IV (intravenous) pain medication and IV (intravenous) anti-emetics. Surgery confirmed acute cholecystitis.

Postoperatively, the patient had excessive drainage from a wound left open and packed. There was also persistent bleeding from the wound edges that required additional suturing on postoperative day #1.

The health plan denied coverage of the inpatient admission, noting that the hospital stay met none of the MCG (Milliman care guidelines) criteria for acute inpatient admission. The denial was appealed based on the need for emergent surgery.

The Inpatient Hospital Admission was medically necessary.

The patient does meet the criteria for medical necessity based on two specific definitions in the MCG (Milliman Care Guidelines). 

1) Emergent procedure - The patient had a pre- and post-operative diagnosis of acute cholecystitis. This is based on the admitting findings of a positive Murphy's sign, the high clinical suspicion of acute cholecystitis on the CT (computed tomography) report and the elevated WBC (white blood cells) with elevated immature granulocytes. This is confirmed with the findings at surgery of an inflamed gallbladder with pericholecystic fluid.

2) Operative site complications - Documentation in the patient's chart confirms excessive drainage and saturated dressing. Also noted is bleeding from the patient's wound required additional sutures to be placed by the attending surgeon as per his note.

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Picky eater, feeding difficulties, dysphagia, and food refusal secondary to sensory and oral motor deficits
Treatment: Speech Therapy Services (Feeding Program)
The insurer denied the Speech Therapy Services (Feeding Program).
The denial is upheld.

This patient is a school-aged child with the diagnosis of being a picky eater, feeding difficulties, dysphagia, and food refusal secondary to sensory and oral motor deficits. The child has been referred to a speech therapy program specializing in feeding. Initial treatment with skilled speech therapist has been approved by the health plan. The subsequent seven month treatment plan has not been approved based on the lack of medical necessity.

The proposed speech therapy services (feeding program) are not medically necessary.

Clinical records do not provide information in support of medical necessity for ongoing feeding therapy interventions for this child. The child has been receiving skilled speech therapy interventions for several years for feeding difficulties. The child does not have evidence of deficits in speech and swallowing mechanisms requiring skilled pediatric speech therapy intervention for such a prolonged time. Clinical records do not identify recent surgery, hospitalization, or illness requiring skilled speech therapy intervention. Clinical records do not support evidence of congenital defect or developmental disorder. Finally, review of medical records points out a steady progress in eating and steady carryover of the skills that this child attained during at least three years of continuous interventions. Therefore, at this time, speech therapy/feeding program is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Ovarian Vein Embolization
The insurer denied outpatient procedure (Ovarian Vein Embolization)
The denial is: Upheld.

The patient is a female with Factor five (V) Leiden deficiency who has had 4 children and may decide to have more. She presents with dull pelvic pain and pressure. Computed tomography venography (CTV) shows significant bilateral ovarian vein reflux from dilated ovarian veins filling pelvic venous plexus. The patient's treating provider wishes to perform ovarian vein embolization. The subject under review is whether the requested service is likely to be more beneficial for this patient than any standard treatment.

The proposed treatment is not likely to be more beneficial for this patient than anything standard options. There is a lack of peer-reviewed literature supporting the efficacy of ovarian vein embolization for the treatment of pelvic congestion syndrome compared with other medical techniques of hormonal therapy, analgesics, physical therapy, etc. The data supporting the diagnosis and treatment of pelvic vein incompetence in the presence of chronic pelvic pain are limited and of variable quality, and higher quality research is required to thoroughly address the research question. Although some research has shown that treatment of pelvic varices provides symptomatic relief in some women, the studies are small case series from which conclusions cannot be drawn with confidence.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Ovarian Vein Embolization
The insurer denied outpatient procedure (Ovarian Vein Embolization)
The denial is: Overturned.

The patient is a female with history of factor five (V) Leiden deficiency, and thrombophlebitis in right lower extremity (RLE), who presented with continued heaviness and aching in pelvis and legs worse with standing, walking, and during pregnancy, no new complaints. The subject under review is whether the proposed treatment outpatient procedure (ovarian vein embolization) is likely to be more beneficial for the patient's condition.
The proposed treatment ovarian vein embolization is likely to be more beneficial for this patient than any standard treatment for her condition. The treatment is safe and effective. Per the patient's treating provider, the patient is a good candidate for the requested coil embolization and given her history of lower extremity (LE) thrombophlebitis, venous insufficiency in the ovarian veins and pelvic varices is the cause. Computed tomography (CT) showed enlarged ovarian vein, CT showed LE varices predominately collateralizing to the left internal iliac vein, borderline dilation of the gonadal vein equivocal for pelvic congestion syndrome. Ovarian Vein embolization procedure is not experimental or investigational and is supported by medical literature in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Ovarian Vein Embolization
The insurer denied outpatient procedure (Ovarian Vein Embolization)
The denial is: Overturned.

The patient is a female with varicose veins in the right lower extremity, and right leg pain with standing, and walking. She also has leg heaviness and swelling. These symptoms were worse during pregnancy. On physical exam, there is a discrepancy in the size of the legs with the right being approximately 30% (percent) larger than the left. Additionally, the patient has pelvic pain and discomfort that is worse with standing and was worse during pregnancy. She has developed vulval veins at all times which were worse during pregnancy. She has an underlying factor five (V) Leiden deficiency. The patient underwent a right lower extremity Doppler which demonstrated persistent sciatic vein (PSV) enlargement with significant reflex. She underwent a computed tomography (CT) venogram that demonstrate venous collaterals from the lower extremity to the labial folds, left greater than right with collateral veins to the internal iliac veins. There was mild dilation of the gonadal veins. The patient wishes to become pregnant in the future. She has been seen by interventional radiology who based on imaging, history, and physical exam has recommended that she undergo diagnostic venography with probable embolization of the bilateral ovarian veins. This treatment plan is currently being denied by her health plan as it is considered experimental.

The proposed health service (Ovarian Vein Embolization) is likely to be more beneficial than any other standard treatment for the insured disabling condition. Multiple studies have found a statistically significant sustained decrease in pain as measured by visual analog pain scales (1). Additional studies have reported significant reductions in pain on standing and lying down, dyspareunia, dysmenorrhea, and in the use of analgesic medications with studies showing 50-80% of women having clinical improvement at long-term follow-up (2). Alternatives to this proposed health service would include open surgical ligation of the gonadal veins, which is more invasive and would require significant post-operative recovery, as well as general anesthesia and overnight hospitalization. The outcomes of this open surgical technique are no better than the endovascular embolization technique (3). There is good medical literature supporting this treatment as being safe and effective. Based on the submitted information, this patient would be a good candidate to receive this therapy and it is expected that she will have a good outcome, relieving her symptoms via a minimally invasive approach.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain.

Treatment: Injection to treat low back pain (procedure code 64484).

The insurer denied coverage for injection to treat low back pain (procedure code 64484).

The denial is overturned.

 
The medical records were consistent for a diagnosis of lumbar radiculopathy. There were ongoing subjective complaints, positive physical findings and correlative imaging to define her pain generator. A course of conservative treatment had been provided. Her back pain would likely benefit from additional epidural steroid injections. The documentation showed she had received two prior injection series. If benefit is reported, the next step would be to proceed with injection series #3. The physician has clarified that only two prior injections were given. The third injection should be authorized with denial overturned. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a third injection to treat low back pain (procedure code 64484) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bilateral Wilms' tumors.
treatment: genetic testing.
the insurer denied genetic testing. 
The health plan's determination is upheld. 

The patient is a male with a history of macrosomia and bilateral Wilms' tumors. He was treated on the Children's Oncology Group (COG) protocol AREN0534. The provider is concerned about Beckwith-Wiedemann syndrome (BWS) and has recommended genetic testing, stating that this testing will help to determine the patient's risk of hepatoblastoma and possible need for surveillance scans after completing chemotherapy treatment for the Wilms' tumor. A genetic panel was sent by nephrology that looks for chromosomal mutations. 

The genetic testing is not medically necessary for this patient.
This patient has a history of bilateral Wilms' tumors and macrosomia, with clinical symptoms suggestive of Beckwith-Wiedemann Syndrome (BWS). The Milliman Care Guidelines (MCG) for gene testing in the setting of BWS notes that for those patients with clinical findings suggestive of BWS, there must be either a family history of BWS, abdominal wall defect, cleft palate, or note that cytogenetic, methylation, or uniparental disomy test results are indeterminate or negative. This patient has not had the negative or indeterminate cytogenetic, methylation, or uniparental testing performed. As per current standards of care, "recommended first-line testing assesses deoxyribonucleic acid (DNA) methylation and copy number variation of the BWS region". While a negative test result does not exclude a diagnosis of BWS, at this stage, additional genetic testing can be pursued for further diagnostic evaluation.
As per an International consensus statement for diagnosis of this condition, if a patient sees clinical criteria for testing, then DNA methylation testing should first be performed. If this is negative, then mosaicism, further testing for rare chromosomal abnormalities, or CDKN1C (Cyclin-dependent kinase inhibitor 1C) analysis should then be considered. As per a review from the National Library of Medicine, over half of the children with this condition have methylation issues, and this type of testing can be potentially confirmatory.
Therefore, based on the clinical information provided for review, and the current standards of care in the field, the genetic testing is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld



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

The patient is a man who presented to the emergency department (ED) following a fall from his bed. There was a reported loss of consciousness. He was initially evaluated in the ED and found to have normal vital signs. Oxygen saturation was 95% on room air. At the time of presentation, he was awake and alert with a Glasgow coma score of 15. Comorbid health conditions included bipolar disorder, seizures, heart disease and anticoagulation with Coumadin. Lab data in the ED identified an elevated prothrombin time (PT) international normalized ratio (INR) of 4.6. Imaging was negative for acute pathology.

The Inpatient hospital admission was not medically necessary in this case. The care and treatment provided on this day could have been rendered with a lower level of care. This patient presented to the ED following a fall in which he sustained no acute injury. He was clinically stable at the time of presentation with normal heart rate, blood pressure, and oxygen saturation. The prothrombin time (PT) international normalized ratio (INR) was elevated. This was trended with daily labs and normalized to 1.97. He remained clinically stable throughout the period of monitoring. A lower level of care would have provided for the care and treatment necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 

This is a young child who had a fever, coughing and wheezing for 1 day. The mother had administered 2 doses of albuterol one hour apart in the home but when she noted rapid breathing in the morning, she brought the child to the emergency room (ER) for evaluation.

In the emergency room (ER) she was noted to have a fever of 101.2 degrees and rhinorrhea. She was described as having mild respiratory distress with mild subcostal retractions. She was noted by the mother to have a decrease in oral intake but a normal urine output. She was treated once with DuoNeb, and one dose of dexamethasone and her examination improved. She was not noted to be hypoxemic on pulse oximetry. A chest x-ray showed peribronchial cuffing and a respiratory viral panel was positive for adenovirus and rhino/entero virus. A venous blood gas was potential of hydrogen (pH) 7.28 and partial pressure of carbon dioxide (pCO2) of 43. The decision was made to admit her to the hospital with a diagnosis of bronchiolitis and a plan to administer albuterol every 2 hours and Atrovent every 6 hours.

The insurer has denied the admission as being not medically necessary.

The patient was treated with only one DuoNeb nebulizer treatment in the ER for coughing, wheezing and increased work of breathing. Her oxygen saturation was normal, and she did not require oxygen supplementation. Her increased work of breathing and wheezing improved with the dexamethasone and DuoNeb. The fact that the mother had albuterol in the home which she administered twice before coming to the ER would imply that the child had episodes of wheezing in the past but there was no mention of this in the medical notes by the ER physicians. Since there was improvement in her clinical state with one nebulization treatment it would be consistent with the standard of care for a child with a history of previous wheezing episodes to receive at least 2 additional nebulization treatments in the ER before making a decision to admit the child to the hospital. Had the child continued to improve with standard of care in the ER she could have been safely discharged with continued treatment with prednisone and nebulized albuterol in the home every 4 hours with a follow up visit with a pediatrician in 24 - 48 hours. This child with a history of treatment with albuterol in the past who presented with mild retractions and wheezing that improved with one dose of DuoNeb and dexamethasone was not treated with the standard of care. The decision to admit was not consistent with the standard of care and there was a possibility that the child would have continued to improve with additional nebulization treatments in the ER.

Based on the above, the insurer's denial must be upheld. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Aortic insufficiency, pulmonary disease, macrocytic anemia
Treatment: Skilled Nursing Facility
The insurer denied coverage for a Skilled Nursing Facility
The denial is upheld

This is an adult patient with chronic medical problems including aortic insufficiency (status post aortic valve replacement), pulmonary disease and macrocytic anemia. The patient was transferred from the hospital to the skilled nursing facility. Under review is the medical necessity for continued stay in a skilled nursing facility (SNF).

The patient was initially an appropriate candidate for the SNF subacute rehabilitation level of care. The patient had functional impairments amenable to (subacute) rehabilitation therapy. The patient received physical and occupational therapy with documented functional improvement. According to the physical therapy note, the patient was independently ambulating with a rolling walker approximately 250 feet. A similar level of improvement with activities of daily living (ADL) tasks was documented by the occupational therapist (supervision to independent for hygiene/grooming, bathing, toileting, dressing). For the time period under review, the patient could have been safely transitioned to a lower level of care. In addition, there were no specific acute medical or complicated nursing issues to support continued stay in a skilled nursing facility.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued stay in a skilled nursing facility was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for continued stay in a skilled nursing facility is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Prostate Cancer
Treatment: Surgical Services/Cryo Treatment 
The health plan denied the requested cryo treatment as not medically necessary. 
The health plan's determination is upheld.

This patient is a man with low risk low volume Gleason Grade Group 1 prostate cancer. He was recommended to undergo focal cryoablation of the prostate as primary therapy for his disease. The use of this procedure is the topic of this review, based on current literature and published data.
At issue is the medical necessity for the requested cryo treatment.

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

No. Per current guidelines of the American Urological Association (AUA) as well as National Comprehensive Cancer Network (NCCN), focal therapy for prostate cancer is considered experimental for treatment naive (primary) patients. It may be considered for radiorecurrent disease, however. Based upon health plan policy, as well as guidelines of the NCCN and AUA, the denial determination is upheld.
Per the appended InterQual policy, use of focal prostate cryosurgery as treatment for this patient's prostate cancer is endorsed when the patient meets specific criteria:
1. Prostate volume < 40 milliliters.
2. Low or intermediate risk.
3. Life expectancy > 10 years.
This patient meets these criteria.
However, the health plan policy classifies the procedure as experimental, as no current literature has established the procedure as beneficial to long term health outcomes. Research findings in the cited articles note the observational nature of the studies. The plan also cites the Cochrane review, which compared cryosurgery to radiotherapy; studies were of low quality and had notable study limitations, therefore, additional confirmatory research was recommended.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Home Health Care (HHC). 

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Live In). The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, overactive bladder, hypertension, gastroesophageal reflux disease (GERD), gout, gastrointestinal (GI) bleed, severe aortic stenosis, coronary artery disease, hyperlipidemia, hearing loss, osteoarthritis, and osteoporosis who had been assigned PCA (personal care assistant) services. 

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Live In) are medically necessary for this patient. 
There is documentation from the patient's designee and healthcare proxy as well as the universal assessments performed of worsening physical and mental functioning and assistance needs with all activities of daily living (ADL)/Instrumental activities of daily living (IADL). The patient requires at least maximum assistance with walking, locomotion, transfer toilet and toilet use and therefore, has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has documented 24-hour care needs and therefore tasking tool should not of been utilized to calculate personal care assistance (PCA) hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Live In) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.