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

Diagnosis: Confusion, dizziness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of alcohol use disorder and polysubstance use disorder. She was admitted after presenting with complaint of confusion, dizziness and awakening on the floor.

On presentation, the patient's vital signs were normal, neurological examination was normal and CT (computed tomography) brain was negative. She was admitted for suspected seizure. She had EEG (electroencephalogram) and MRI (magnetic resonance imaging) that were negative for significant abnormality. She had no recurrent events and was discharged without an anticonvulsant.

No, the Inpatient admission was not medically necessary.
The member was suspected of having a single seizure. At presentation she was at her baseline neurological status. There were no recurrent events and diagnostic studies were negative for acute pathology. The neurological assessment, monitoring, treatment and diagnostic studies could have been safely and effectively provided at a lower level of care (Shellhaas; Foster et al.).

Yes. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Alzheimer's disease.
Treatment: Home care / personal care Home Health Care (HHC) - level 2 personal care services, per 15 minutes increase to 24 hours per day live in.
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in.
The denial is modified.

This is a patient with multiple chronic medical problems including Alzheimer's disease. He lives alone. The patient is currently approved for at home care / personal care HHC - level 2 personal care services (PCS), per 15 minutes 49 hours/week.  

According to the Uniform Assessment System (UAS) report, the patient's cognitive status is "minimally impaired." However, he is "dependent in all decision making" and "unable to express his goal due to cognitive impairment." The patient requires maximal assistance for bathing, dressing, and toilet use. He is occasionally bowel and bladder incontinent. Extensive assistance is needed for personal hygiene, bed mobility and ambulation. His overall functional ability has declined since the prior assessment particularly for bathing, dressing, toilet transfer/use, bed mobility and ambulation. The combination of the patient's decreased cognitive status, medical condition and (declining) functional ability support the medical necessity of increasing level 2 personal care services, per 15 minutes from 49 hours per week to 84 hours per week. However, his condition and functional needs are not at a level or unpredictable as to require the requested 24 hours per day (live-in) PCA services. This physician would also agree the patient may require 24-hour monitoring. However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided.  

From a physical medicine and rehabilitation perspective, level 2 PCS, per 15 minutes increase to 24 hours per day live in is not medically necessary. However, increasing level 2 PCS, per 15 minutes to 84 hours/week is medically necessary.

The insurer's denial of coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical radiculopathy

Treatment: outpatient procedure code 62321 x 1, cervical epidural steroid injection (CESI)

The insurer denied coverage for outpatient procedure code 62321 x 1, cervical epidural steroid injection (CESI)

The denial is overturned

This patient a history of cervical radiculopathy. She presented to the Orthopedist's office for the evaluation of neck pain. The patient reported participating in physical therapy (PT) three times a week for six weeks without improvement. She has also tried medical massages, chiropractic treatment, and pain medications without relief. The physician recommended a cervical epidural steroid injection (CESI) to treat neck pain.  

The medical records were consistent for ongoing subjective complaints of a radicular nature. The woman was found to have positive physical findings in a unilateral distribution. She was found to have positive imaging studies of multilevel nerve root compression and degenerative disease. She received a full course of conservative treatment which included medications, chiropractic, massage, and 6 weeks of PT. 

Her symptoms were consistent for a radiculopathic pain syndrome. The next step would be the cervical epidural steroid injection as recommended. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Outpatient procedure code 62321 x 1, epidural steroid injection is considered medically necessary for this patient.

The insurer's denial of coverage for outpatient procedure code 62321 x 1, epidural steroid injection is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain, nausea, vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male presented who presented with three days of epigastric pain, nausea and vomiting. He felt he might have ingested a salmon bone. He was mildly hypertensive in the emergency room, without fever or tachycardia. He had a mildly decreased sodium of 130, and normal liver function tests (LFTs). Computed tomography (CT) revealed a 2.9 centimeter non-obstructing foreign body in the distal small bowel, as well as thickening in the stomach and a mild dilated bile duct. He was hydrated and seen by gastroenterology (GI) who recommended advancement of diet and outpatient evaluation with follow up imaging and possible esophagogastroduodenoscopy (EGD). 

The patient's sodium was 133. Magnetic resonance cholangiopancreatography (MRCP) revealed a possible ampullary stricture, and he was seen by advanced gastroenterology who recommended outpatient esophagogastroduodenoscopy (EGD)/endoscopic ultrasound (EUS) and possible endoscopic retrograde cholangiopancreatography (ERCP). The patient was discharged.

No, the proposed inpatient hospital admission was not medically necessary.
As the patient was hemodynamically stable, without need for prolonged nothing by mouth (NPO), endoscopic intervention, without gastroenterology (GI) bleeding, obstruction or intractable vomiting, observation status was medically necessary. He was tolerating a diet, his sodium was rising, there was no further vomiting, and as he was planned for outpatient follow up, he was medically stable for discharge to outpatient care. Therefore, acute inpatient stay was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
As acute inpatient stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Buttock pain

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

This patient, who appears to have been otherwise healthy, presented with a one-week history of buttocks pain that was diagnosed as a pilonidal abscess. On examination it was a very tender 2 cm (centimeters) by 2 cm, fluctuant intergluteal mass with an area of surrounding cellulitis. She underwent a surgical pilonidal cystectomy with drainage and packing, under general anesthesia for which she was intubated. 15-20 mL (milliliters) of purulent fluid was drained and she needed intravenous (IV) morphine for severe postoperative pain, as well as a return to the operating room for packing removal. All these procedures necessitate an inpatient level of care. 

Moreover, by Milliman Care Guidelines (MCG Pediatric) criteria, she had: 

1) "Associated surgical procedure (e.g. [for example], abscess drainage, debridement) not amenable to outpatient, emergency department, or observation care". 2) "Inpatient admission required rather than observation care because of 1 or more of the following: perineal infection that is severe or persistent [or] severe pain requiring acute inpatient management".

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

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This male patient was hospitalized for syncope. The patient had passed out while doing laundry. His past medical history (PMH) includes hypertension, diabetes, seizure disorder, asthma, tobacco abuse, alcohol (ETOH) abuse, obesity and major depressive disorder. 

The patient's vitals were stable and he was slow to answer questions.  His computed tomography of the head was negative.  His electrocardiogram showed sinus rhythm and was negative for ST-elevation myocardial infarction (STEMI).  His chest x-ray was unremarkable and alcohol level was less than (<) ten. The clinical impression was orthostatic hypotension and alcohol abuse. Treatment included intravenous fluid resuscitation and he became ambulatory and was discharged to home. This is an appeal of the denied claim the requested acute inpatient hospital stay was not medically necessary for this patient.

No, the proposed inpatient hospital admission was not medically necessary.
Based on the current peer reviewed medical literature, including the Milliman Care Guidelines (MCG) for syncope, the requested inpatient stay is not medically necessary, as criteria for inpatient stay are not met for suspicion of imminently dangerous cause, like pericardial tamponade, pulmonary embolism, or syncope causing injury requiring hospitalization.  Inpatient admission would be required rather than observation care because of a significant finding or clinical condition judged too severe or too persistent to be within scope of observation care, such as hemodynamic instability that is severe or persistent, cardiac arrhythmias of immediate concern, acute coronary syndrome or myocardial Infarction, structural cardiac disorder like severe aortic stenosis or suspected as cause that requires immediate correction, respiratory distress, stroke, seizures, persisting altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding or clinical condition judged not to be within scope of observation care. 

The patient's vitals were stable and he was slow to answer questions. His computed tomography of the head was negative. His electrocardiogram showed sinus rhythm and was negative for ST-elevation myocardial infarction (STEMI). His chest x-ray was unremarkable and alcohol level was less than (<) ten. Therefore, the proposed treatment was not medically necessary, based on the submitted documentation and the current evidence-based guidelines.

Yes, the health plan did act reasonably, with sound medical judgment and in the bets interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

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

This man presented to the emergency department complaining of five days of intermittent chest pain. His past medical history was remarkable for coronary artery disease, myocardial infarction and hyperlipidemia. His blood pressure was 137/77 with a heart rate of 87 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 98%. An electrocardiogram showed sinus rhythm without acute changes. His serum troponin I level was 0.004. His creatinine level was 1.33 (his baseline level was not documented). His creatine kinase (CK) level was 2126. His electrolytes were normal. Chest X-ray showed no acute pathology.
The patient was treated with intravenous fluid and admitted to the hospital with diagnoses of rule out acute coronary syndrome, possible acute kidney injury and mild rhabdomyolysis. 

The inpatient level of care was not medically necessary.
This patient, with known coronary artery disease, presented with chest pain. He was hemodynamically stable, without evidence of acute electrocardiographic changes or decompensated heart failure. While his serum troponin level was mildly elevated, this was not attributed to acute coronary syndrome (ACS) and no intervention for ACS was deemed warranted. The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. The care he received for his chest pain did not require an inpatient admission and could have been provided under "observation" status. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Upon presentation the patient was noted to have an elevated creatine kinase level (CK) consistent with mild rhabdomyolysis. He did not have electrolyte abnormalities, coagulopathy, compartment syndrome or other complications of severe rhabdomyolysis. While his serum creatinine level was mildly elevated it remained stable, it was unclear if the elevation was acute, and there was no documentation of myoglobinuria. The only treated provided was intravenous hydration. This did not require an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adrenal Insufficiency
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned 

Patient is a female who was diagnosed with Post-Partum Sheehan's Syndrome. She has other past medical history (PMH) of hyperlipidemia (HLD), diabetes mellitus (DM) and Depression. The patient presented to the emergency department (ED) with complaint of (C/O) Weakness, Near Syncope. Patient C/O some nausea, vomiting and diaphoresis symptoms.

Patient had hypotension noted in ED (emergency department) with blood pressure (BP) in 90/60 mm Hg (millimeters of mercury) range. She was started on intravenous (IV) hydration. She was in no acute distress (NAD). Lungs were clear Cardiovascular (CVS) s1 (heartbeat) S2 (heartbeat) normal. The patient was alert and oriented (A x O X 3). Neuro exam was Non focal.

Labs revealed white blood cell count (WBC) of 10.8K (thousand) Hb (hemoglobin) 15.9 Electrolytes were within normal limits (WNL) BUN (blood urea nitrogen) / Creatinine 21/0.8.

The patient's Cortisol Level was 1.2 and TSH (thyroid stimulating hormone) was 0.9.

Chest x-ray was WNL and Pulmonary computed tomography (CT) Angiogram was negative for pulmonary embolism (PE).

Patient was diagnosed with Acute on Chronic Adrenal Insufficiency. Other possibilities included Hypovolemia secondary to dehydration, Cardiac/Neurological or a Vasovagal episode.

Patient was admitted to Telemetry. Myocardial infarction (MI) was ruled out (R/o) by serial Troponins and EKG (electrocardiogram). Patient was continued on IV fluids. Prednisone dose was initially increased from 5 mg (milligrams) daily to 15 mg /day.

The patient was transferred out of Telemetry but continued to remain hypotensive with Systolic BP in 90's with readings as low as 91/60.

The patient was evaluated by Endocrinology. They recommended to increase prednisone dose to 30 mg in the AM (morning) and 15 mg in PM (evening). Patient was also placed on Thyroid replacement with Levothyroxine.
 
This patient most likely had Acute on Chronic Adrenal Insufficiency and needed adjustment of her Steroid dosing. Adrenal insufficiency is a life-threatening condition and needs to be treated promptly and aggressively. The patient continued to have episodes of hypotension even after that. Therefore, it was appropriate to keep the patient in hospital to monitor for signs and symptoms of acute adrenal insufficiency.

The patient slowly stabilized with increased dose of steroids and thyroid replacement as per Endocrine recommendations and was discharged (dced) after stability was achieved.

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Acthar Gel. 
The denial is overturned.

The patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.

The health plan's determination is overturned.

This patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be medically necessary and appropriate as the next step in the treatment of this patient.

Acathar gel has been Food and Drug Administration (FDA) approved for patients with severe acute and chronic allergic and inflammatory processes involving the eye and its adenoma. This includes keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, and anterior segment inflammation. This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be an appropriate as the next step in the treatment of this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep apnea
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld. 

The patient is a female with sleep apnea. Per the records provided, the patient could not tolerate continuous positive airway pressure (CPAP). The patient also had nasal obstruction. Nasal steroids had been attempted.

A UVP (Uvulopalatoplasty), tonsillectomy, septoplasty and turbinoplasty were carried out. No operative complications were noted. The patient was admitted as an inpatient.

The inpatient hospital admission was not medically necessary. 

The patient had an uncomplicated UVP, septoplasty and turbinate reduction. There was no documentation of any operative complications. There was no documentation of unstable vital signs. There was no documentation provided that supported the medical need of an inpatient hospital stay. The patient could have been managed at a lower level of care which allows for an overnight stay.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ear/Nose/Throat
Treatment: Surgical Services - Balloon dilatation Eustachian Tuboplasty
The insurer denied Balloon dilatation Eustachian Tuboplasty. 
The denial is upheld.

The patient is a female with eustachian tube dysfunction. Her previous treatment has included ear tubes. The patient has a right ear drum perforation on exam and hearing test shows a moderate right sided conductive hearing loss. A tympanoplasty with ear tube has been proposed. A provider note states that it is unclear "duration of benefit" from balloon eustachian dilatation.

At issue is whether the Balloon dilatation Eustachian Tuboplasty is likely to be more beneficial than any standard treatment or treatments.

The health plan's determination regarding the proposed health treatment is upheld in whole.

The proposed health service or treatment Balloon dilatation Eustachian Tuboplasty (BDET) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No studies have shown that balloon eustachian dilatation is more beneficial than ear tubes. The treating provider documented in her note that the "duration of benefit" for this procedure is unclear. Although balloon dilatation of the Eustachian tube provides exciting research for chronic eustachian tube dysfunction, the literature does not support long term effectiveness. Although the procedure is safe, there is no strong, high-quality evidence that this procedure is effective. A recent systemic review concluded, "Due to the limited and poor-quality evidence it is inappropriate to make conclusions on the effectiveness of any intervention; the evidence base is insufficient to guide recommendations for a trial of any particular intervention. Consensus on diagnostic criteria for Eustachian tube dysfunction is required to inform inclusion criteria of future trials." (Norman 2014)

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) recently released a clinical consensus statement. It should be noted that this document stated, "Consequently, the panel ultimately could not reach consensus regarding the overall short-term or long-term effectiveness of BDET." 

A systemic review by Randrup concluded "The evidence of BET is poor and biased. No firm conclusions can be made to identify patients who will benefit from the procedure or to accurately predict surgical results. Randomized controlled trials or case-control trials are needed."

Therefore, the proposed health service or treatment Balloon dilatation Eustachian Tuboplasty (BDET) is not likely to be more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/musculoskeletal
Chiropractic services

Diagnosis; neck/back pain
Treatment: Chiropractic care
The insurer denied chiropractic care. The health plan's determination is upheld.

The patient is a female who presented with complaints of neck and upper back pain, of one week's duration. Treatment included chiropractic manipulation, mechanical traction and ultrasound. Treatment continued for six months under the same treating diagnoses and chief complaints.

Chiropractic Services are not medically necessary for this patient.
The patient was being treated on a monthly basis from the start of care for unchanging chief complaints and diagnoses. This is the definition of maintenance care. As such, a medical endpoint had been reached. There was no new episode or injury.
In this case, there was no ongoing objective evidence of clinical improvement, and maximum therapeutic benefit had been achieved. At this point, the standard of care would be to perform additional diagnostic procedures or refer the patient for alternative treatment. Therefore, the requested chiropractic services were not medically necessary.