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

Diagnosis: Dementia, urinary incontinence 
Treatment: Level I personal care worker (PCW) services, seven days/week, 12 hours/day, total 84 hours/week 

The insurer denied the Level I personal care worker (PCW) services, seven days/week, 12 hours/day, total 84 hours/week. The denial is upheld. 

No, the proposed treatment of an increase in personal assistance services to level I PCW services, seven days/week, 12 hours/day, total 84 hours/week is not deemed medically necessary. 

The patient is a female with a history of dementia, hypertension, urinary incontinence, dizziness, chronic low back pain, chronic bilateral knee pain and type II diabetes mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

An in-home assessment of the patient's functionality and ability to perform ADL's was completed and revealed that the currently approved plan of 35 hours/week personal assistance services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of an increase in personal assistance services to level I PCW services, seven days/week, 12 hours/day, total 84 hours/week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Inpatient Hospital.
Diagnosis: Syncope.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
 The health plan's determination is upheld. 

The patient is a female with a complex past medical history. She was admitted through the emergency room secondary to the syncopal attack. She was admitted and evaluated in the hospital.

The acute inpatient hospital admission is not medically necessary for this patient. The patient could have been monitored at a lower level of care. The patient has a cardiac pacemaker with no underlying cardiac events noted on the interrogation. Blood pressure showed no significant episodes of orthostasis. Laboratory data showed no significant abnormalities in blood count or chemistry studies. There is no evidence of sepsis or other infection. Evaluation by her physician stated no further need for inpatient electroencephalogram (EEG) or other neurological monitoring due to the recent previous workup. A lower level of care was appropriate and an inpatient stay was not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal.
Treatment:  Inpatient Hospital.

The insurer denied the Inpatient stay.  The denial is upheld in whole.

The patient is a male with periumbilical abdominal pain who presented to the emergency department (ED) for evaluation which included blood work, computed tomography (CT) and ultrasound.  No leukocytosis, CT inconclusive for appendicitis (but not suggestive), as was ultrasound.  Surgery was not offered.  The patient was admitted overnight and did well.  He was discharged the next day.  The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld in whole.

An acute inpatient stay was not medically necessary.  The patient could have been safely and appropriately managed at a lower level of care status.

An inpatient stay might be justified if there was a serious medical or surgical condition identified, which required more complex management.  However, this patient was simply observed with symptomatic treatment for abdominal pain.  There were no complications with this pain, no physiologic derangements, hemodynamic instability, acute or chronic organ dysfunction, persistent altered mental status, fever or other signs of sepsis, management of complex comorbid medical condition or a finding of an occult or new medical condition.

Even if surgery had been needed for treatment of an otherwise healthy adolescent with acute appendicitis, it is routinely provided at a lower level of care status.  No evidence was presented in the appeal documentation or in the primary medical records that would indicate that the patient had a serious medical condition requiring inpatient admission.

Based on the literature and widespread experience with modern treatment of pediatric acute abdominal pain (which is most commonly due to conditions such as appendicitis, mesenteric adenitis, or gastroenteritis), an inpatient acute level of care is not justified.  If patients have evidence of physiologic compromise that would indicate medical necessity for a higher acuity of care, it should be evident in the records.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System 
Inpatient Hospital 

Diagnosis: Fever, shortness of breath 
Treatment: Inpatient stay 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a man who presented to the emergency department with a chief complaint of fever for the past two days. He reported a productive cough and wheezing and also stated that he had stopped taking his medications for heart failure approximately six months earlier. Past history included alcohol abuse and heart failure. He denied chest pain, nausea, vomiting and abdominal pain. 

The inpatient stay was medically necessary. The patient presented with acute respiratory failure and required support with mechanical ventilation/BiPAP in the emergency department and BiPAP was continued after admission, albeit briefly. He had both hypoxia and tachypnea, and he met sepsis criteria with tachycardia, fever, elevated white blood cell count, and a suspected source of infection. The patient required intensive care for stabilization and was at increased risk for worsening respiratory failure and need for more invasive mechanical ventilation. He met sepsis criteria and had multiple risk factors for worsening sepsis, worsening respiratory failure, and an adverse outcome. It would not be appropriate to manage a patient with his risk factors and signs/symptoms at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Age-Related Nuclear Cataract
Treatment: Refractive Surgical Procedures
The insurer denied the Refractive Surgical Procedures.
The denial is upheld. 

The patient is a female. She underwent cataract extraction with intraocular lens and laser astigmatic keratotomy (66999) of the right eye.  

Per operative report  - diagnoses of nuclear cataract and astigmatism right eye; operation performed is phacoemulsification cataract extraction with intraocular lens right eye and femtosecond laser astigmatic keratotomy right eye.  

Prior reviews recommended non-certification as the femtosecond astigmatic keratotomy was considered not medically necessary.  

No, the proposed treatment is not medically necessary.

Astigmatism is an imperfection in the curvature of the eye's cornea or lens.  Astigmatism treatment includes glasses, contact lenses, or surgical procedures at the time of cataract surgery including femtosecond laser astigmatic keratotomy (which uses laser to change the shape of the cornea and treat astigmatism).

After cataract surgery, any residual astigmatism or refractive error can be corrected with glasses or contact lenses.  A newer technology involves femtosecond laser assisted refractive-cataract surgery.  

Per the American Academy of Ophthalmology Preferred Practice Patterns - "Although innovative and exciting, femtosecond laser-assisted refractive-cataract surgery offers some surgical and financial challenges. A systematic review found that available evidence could not evaluate equivalence or superiority of this surgery over standard phacoemulsification. In conclusion, there are many nuances, advantages, and disadvantages, and these all need to be reviewed and considered. Femtosecond laser assisted cataract surgery appears to be a comparably safe and reproducible technology, but further prospective randomized studies are needed to demonstrate the potential clinical utility."

Medically necessary covered services are those that are:
1) required to diagnose or treat an illness, injury, disease or its symptoms [NOT MET]
2) not primarily for the convenience of the patient, Physician or other health care provider [NOT MET]

In this case, the astigmatic keratotomy was not required to treat the patient's astigmatism, and was primarily for the convenience of the patient/Physician, as the astigmatism could have been treated with standard glasses.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient presented with a right buttock abscess and elevated white blood cell (WBC) count. She underwent bedside debridement in the ED(emergency room) and was admitted for intravenous antibiotics. Her Xarelto was held. She underwent additional debridement and was discharged.

Yes, the proposed inpatient admission was medically necessary.

The patient presented with a right buttock abscess and elevated WBC count. She had very recently undergone left femoral endarterectomy and iliac stenting. She had an extensive history of hypertension, diabetes, congestive heart failure (CHF), atrial fibrillation, and peripheral vascular disease (PVD). Her buttock abscess was remote from the surgical site and close to the perineum. It had a foul odor with purulent drainage and overlying eschar. Her WBC count was 18,900 with significant left shift (86% neutrophils). She underwent bedside debridement in the ED and was admitted for broad-spectrum intravenous antibiotics. Her Xarelto was held. She developed significant anemia (hemoglobin 6.4), for which she was transfused. She underwent additional debridement and was discharged on oral antibiotics.

The admission was medically necessary for multiple reasons:
1) The patient had a severe and unexpected infectious problem, namely, right buttock abscess close to the perineum. She had underlying pus and overlying necrotic skin. The severity of the abscess and the lack of obvious etiology required inpatient management.
2) Abscesses in the perineal location must be managed aggressively because of the risk of necrotizing fasciitis, sometimes referred to as Fournier's gangrene. Early debridement and intravenous antibiotics are essential elements of treatment, along with close monitoring. Such treatment can only be done in the acute care setting. 
3) During the hospital stay, she developed significant anemia, requiring blood transfusion. This treatment, which can only be done in the acute care setting, required continuation of her hospital stay. Treatment involved giving blood and monitoring her hemoglobin afterward.

The case was reviewed internally by the health plan under the guidelines for cellulitis. However, these guidelines are not applicable in this case. The patient did indeed have cellulitis, but her underlying condition was more serious than a simple problem of cellulitis for reasons described above. The cellulitis guidelines therefore cannot be directly applied to this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: #14 Broken cusp
Treatment: Crown on tooth #14 
The insurer denied the Crown on tooth #14.
The denial is overturned.

The patient is a female requesting dental benefit coverage for a crown on tooth #14.

Yes, the proposed crown on tooth #14 was medically necessary.  Tooth #14 had a very large old amalgam filling which had fallen out.  One of the four cusps (MB) had also broken off. A tooth like this one, which presents with a large, existing restoration and especially with a cusp missing, always needs a crown to prevent future breakage and eventual extraction. The crown is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Proton Beam Radiation Therapy
The insurer denied the Proton Beam Radiation Therapy.
The denial is upheld. 

The patient is a female with a diagnosis of loco-regionally advanced (cY3N1M0) right breast carcinoma s/p (status post) neoadjuvant chemotherapy followed by bilateral mastectomy and axillary dissection.  Adjuvant radiation therapy was recommended, and proton beam radiation therapy was requested.  

No, the Proton Beam Radiation Therapy was not medically necessary.

In this case, the patient is a female with a diagnosis of loco-regionally advanced (cY3N1M0) right breast carcinoma s/p neoadjuvant chemotherapy followed by bilateral mastectomy and axillary dissection.  Adjuvant radiation therapy was recommended, and proton beam radiation therapy was requested.  However, based upon and in conclusion of the review above, the proposed treatment is not considered medically necessary for this individual under these unique circumstances.
		
Proton beam radiation therapy (PBRT) is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions.  Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose."  A proton beam also has a high-dose "Bragg peak" region, which is designed to cover the entire tumor, and there is no "exit dose" beyond the tumor involved in proton radiation therapy.  Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects.  It is an FDA approved procedure and it is not subject to IRB (institutional review board) review.

Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures, such as CNS (central nervous system) lesion, there is insufficient clinical peer-reviewed literature for supporting its use for the treatment of breast carcinoma.  There are other established alternatives available such as conventional conformal or IMRT (intensity modulated radiation therapy) photon therapy that have been shown to be safe and effective for the adjuvant treatment of breast cancer.  There are several phase I and II clinical trails still evaluating the role of proton therapy for breast cancer.  The report of ASTRO's emerging technology committee also does not include proton therapy for breast cancer.  Proton therapy for breast cancer is not considered medically necessary in this case, because has not been shown to be clinically superior in well conducted randomized trials.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ADHD and homicidal behaviors. 
Treatment: Continued Inpatient Admission. 
The insurer denied the Continued Inpatient Admission. 
The denial is overturned. 

This female with a diagnosis of attention deficit hyperactivity disorder (ADHD) was admitted after "poisoning" her mother's drink with a cleaning agent. She poured dish soap into her mother's ginger ale. The patient had a history of multiple previous admissions for "homicidal" behaviors toward family members, in the context of sleep disturbance, increased irritability, and conflict with family members. The patient had previously been discharged with diagnoses of ADHD, oppositional defiant disorder, and conduct disorder and had been treated with Ritalin and weekly family therapy. She was recently discharged from the outpatient program due to overall improvement. 

Multiple Child Protective Service reports were open on this family, but no details were provided. 

The patient was treated with individual and group psychotherapy, psychoeducation, and safety planning. She was given Concerta which was titrated to 27 milligrams (mg) daily, and clonidine, 0.05 mg at bedtime. 

In the hospital, the patient's mood was bright. She was cooperative with ward routine. She admitted to poisoning her mother because she was angry that her brother, who has autism spectrum disorder and behavioral problems, had returned home from this same hospital unit. She expressed remorse for her actions. She stated that her attempt was to harm her mother but not to kill her. However, during the patient's stay, her mother learned from the patient's siblings that she had been "poisoning" her as well as her younger siblings for three years. The mother also reported that the patient had been touching her siblings inappropriately. 

The patient's discharge was delayed because her mother refused to accept telephone calls from staff for one week, and then refused to pick up her daughter on the projected discharge day or to accept her back into the home despite encouragement by hospital staff. The child was placed by court order in the custody of the Administration for Children's Services and discharged as soon as a bed was available. 

Yes, the proposed treatment, continued inpatient admission, was medically necessary. 

Given a long history of dangerous behaviors by the child, and the patient's mother's absolute refusal to take her home, the patient could not have been discharged regardless of her clinical status. Hospital staff acted as expeditiously as possible to arrange alternative placement for this child who was discharged. To have done any less would not have been consistent with the standard of care, as it would have posed an unacceptable risk to the health of the patient as well as the family.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal abscess
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.   

This is a female child no past medical history. The patient presented to the Emergency Room (ER) with lower back pain for the past 2-3 days with swelling last night and redness to her perirectal area.  The patient had been seen on the same day at an Urgent Care center, where an area of spontaneous drainage was drained of "purulent and brown fluid." In the ER, the patient's exam showed purulent drainage, erythema and warmth at her left buttock. The patient had an elevated white blood cell (WBC) count of 23.44, and moderately elevated inflammatory blood markers (C-reactive protein 13.51, and ESR 87). The patient's ultrasound of the buttocks revealed a 3.0 X 0.7 X 1.3 centimeter left upper buttock collection, concerning for fluid collection/abscess. The origin may have been a pilonidal cyst, given descriptions in the chart that the abscess was near her intergluteal cleft.  A bedside incision and drainage were performed under local anesthesia and a wound culture was sent.  The patient was admitted for additional intravenous (IV) antibiotics and received Tylenol and ibuprofen. 

Based on the review of the medical record, the patient was well-appearing. There was no evidence of sepsis, fasciitis, local spared of the purulent infection, or toxic shock syndrome. The inpatient services provided were not medically necessary for treatment of her abscess, which could have been treated with follow-up as an outpatient after drainage by the surgeon in the ER. There is no medical-decision-making statement that adequately justifies this patient's inpatient admission and the need for IV antibiotics. A gluteal abscess of this size and location could have been safely treated as an outpatient after incision and drainage because it is not in danger of spreading to any vital structure or organ (Lawrence and Nopper, 2012). As per UpToDate, IV antibiotics are usually used in this scenario.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal cell cancer, renal cysts. 
Treatment: CPT code 74178 Computed Tomography (CT) scan of the abdomen and pelvis with and without contrast and CPT code 71260 CT scan of the thorax. 

The insurer denied coverage for CPT code 74178 Computed Tomography (CT) scan of the abdomen and pelvis with and without contrast and CPT code 71260 CT scan of the thorax. The denial is upheld. 

This is a male patient with past medical history of hypertension, renal cell cancer status post left nephrectomy (left) in 2016, benign prostatic hypertrophy (BPH), prostate cancer, and positive smoker who presented to his urologist with complaints of nocturia, weakness, and urinary dribbling. The patient had a CT scan of the chest/abdomen/pelvis that revealed multiple prominent right renal peri-pelvic cysts, cholelithiasis, and stable thyroid isthmus thickening. 

Based on the review of the medical record, the patient had a 1.8 cm renal cell cancer treated by left nephrectomy. This is considered a T1A tumor (1.4 cm in greatest dimension, limited to the kidney). This patient is considered a low risk patient. Abdominal imaging is recommended 3-12 months after nephrectomy. After that, abdominal imaging is optional, but may be prudent in patients with risk factors for recurrence, such as positive surgical margin, familial renal cell cancer, or high grade cancer.  If this patient was considered high risk, more frequent imaging with a CT scan, magnetic resonance imaging (MRI) or ultrasound would be recommended for a period of up to 5 years. According to literature review, for stage I disease or low risk patients such as in this case, further abdominal imaging with CT or MRI is indicated for the following reasons: (1) New or worsening abdominal symptoms; (2) New or worsening ultrasound findings; and/or (3) There is a suspicious abnormality on postoperative CT. However, in this case, none of these clinical indications were applicable to warrant further imaging with CT scan. Thus, CT scans of the abdomen/pelvis and thorax were 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 CPT code 74178 Computed Tomography (CT) scan of the abdomen and pelvis with and without contrast and CPT code 71260 CT scan of the thorax should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was overturned.

This is a female patient with a medical history of a recent vaginal delivery who presented to the Emergency Department (ED) with complaints of pelvic abscess. On ED presentation, the patient's vitals included: Temperature of 98.2 F, Blood Pressure of 116/78, Pulse of 80, Respiratory Rate of 18, and Oxygen (O2) saturation of 98% on Room Air. The patient's laboratory results included the following; white blood cell (WBC) count of 5.89, hemoglobin (HGB) of 11.1, hematocrit (HCT) of 33.7, creatinine of 0.5, glucose of 81, and C-reactive protein (CRP) of 7.9. The patient was admitted and was started on intravenous antibiotics (i.e., ceftriaxone and azithromycin) for possible right groin cellulitis. The patient's computed tomography (CT) scan of abdomen/pelvis revealed acute inflammatory changes within the anterior abdominal wall, and a 4.5 x 4.6 x 4.4 cm fluid collection. Surgery service was consulted and they performed an incision and drainage procedure on the patient. From this procedure, 20 cc of pus was expressed. All cultures remained negative. The patient remained afebrile, hemodynamically stable, and was discharged on oral antibiotics (i.e., Augmentin) to continue management as an outpatient.

Based on the review of the medical record and literature, the patient presented with worsening pelvic abscess despite outpatient treatment with oral antibiotics. Medical records described an "8 x 10 cm indurated area with streaking." The patient's computed tomography (CT) scan showed a pelvic collection that required surgical intervention. Based on above findings including documented failure of outpatient management, in a post-partem patient, hospital admission was medically necessary for administration of intravenous antibiotic and surgical drainage.  

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

The carrier's denial of coverage for the acute inpatient stay should be overturned. The medical necessity is substantiated.