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

Diagnosis: Uterine fibroids

Treatment: Continued hospital stay

The insurer denied the continued hospital stay. 

The denial is overturned.

This is a female patient with a history of hypothyroidism and uterine fibroids. She underwent a scheduled laparoscopy followed by a laparotomy with bilateral celiotomy, total abdominal hysterectomy, bilateral salpingo-oophprectomy, radical dissection for debulking, enterectomy with resection in small intestines, and inguino-femoral lymphadenectomy. The patient tolerated the procedure well. The patient was to be discharged 4 days after the procedure; however, she experienced an episode of nausea and vomiting, and was unable to tolerate any oral intake. She was made nothing by mouth (NPO) overnight. The following day she was started on a clear liquid diet. The patient tolerated the diet well and had a bowel movement. Her diet was advanced to solid food and after a period of medical stability she was discharged home.
 
Based on the review of the medical record, this patient underwent extensive surgery including bowel surgery. The patient was doing well until she developed signs and symptoms of prolonged postoperative ileus. No studies have identified any specific therapy, other than supportive care, to resolve prolonged postoperative ileus. Supportive care includes pain control that minimizes opioid use, intravenous fluid and electrolyte therapy, dietary restriction, and selective placement of a nasogastric tube for gastrointestinal decompression for those with persistent nausea/vomiting. Such patients should be closely monitored with serial abdominal examinations for improvement or worsening of their condition. Additional imaging studies are warranted if conservative measures do not improve the patient's condition in 48 to 72 hours.

In this case, continuous admission was medically necessary in order to rule out other causes for this patient's symptoms like small bowel obstruction, bowel perforation, intra-abdominal abscess, or retroperitoneal bleeding. Once these were ruled out, the patient was managed adequately with intravenous hydration, dietary restriction (NPO) and intravenous acetaminophen (opioid restriction) for her pain management. Once the patient was able to tolerate clear liquids and pass flatus and have a bowel movement, the patient was advanced to solid food intake which she tolerated. This level of stability was required for safe discharge home, which was achieved when the patient was discharged home without any other delay.

Based on this review of the medical record and literature, the continuous admission was medically necessary to rule out a serious condition and to manage this patient's symptoms appropriately. This care could not have been provided at a lower level of care.  

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 continued hospital stay should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system /Gastrointestinal Abdominal pain
Treatment: Inpatient hospital stay

The insurer denied the inpatient hospital stay. The denial is upheld in whole. 

This is the case of patient with past medical history of diabetes type 1, depression, anxiety, and prior diagnosis of eating disorder, who presented to the emergency department with nausea, diarrhea, and abdominal pain. The patient had recently been seen at a different emergency department and discharged. 

No, the inpatient stay is not medically necessary. This is a patient who presented with hyperglycemia without diabetic ketoacidosis in the setting of insulin pump dysfunction. The patient  improved quickly with insulin the emergency department, was hemodynamically stable, had her insulin pump adjusted, and her abdominal pain was managed well enough to discharge. It is unclear why in the absence of clear etiology causing her abdominal pain, hemodynamic instability, diabetic ketoacidosis, or other clear process contributing to her hyperglycemia aside from insulin pump dysfunction why she could not have been safely cared for in a lower level of care. As previously noted, she appears to have been safe to treat at a lower level of care in the absence of diabetic ketoacidosis, hemodynamic instability, or other clear process aside from insulin pump dysfunction aggravating her hyperglycemia and causing her abdominal pain requiring inpatient care. Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: DVT (deep vein thrombosis)
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the inpatient admission was not medically necessary.

The patient is a male with history of venous insufficiency, left iliac vein agenesis status post femoral bypass, history of deep vein thrombosis (DVT), who presented to the hospital with complaints of one to two months of worsening lower extremity edema as well as left lower extremity pain.  He denies shortness of breath, cough, chest pain, weakness, abdominal pain and diarrhea.

Of note, the patient was recently discharged from the hospital for deep vein thrombosis, left lower extremity. On discharge, he was prescribed Eliquis; however, he was not taking the medication (pharmacy ran out, as well as insurance issues).

Emergency room vitals: blood pressure 128/87, heart rate 90, respiratory 16, oxygen saturation 100% on room air and temperature between 98.5F and 102.5F.  Physical examination was notable for diffuse lymphedema swelling of the left lower extremity associated with tenderness on the upper left medial aspect of the thigh.  Cardiopulmonary examination was unremarkable.
Laboratory studies: white blood cell (WBC) 6.2, hemoglobin 12.4, hematocrit 37.2, platelets 139, international normalized ratio (INR) 1.1, sodium 137, potassium 4.7, glucose 101, and creatinine 1.11.  Ultrasound of the left lower extremity showed left common femoral and proximal saphenous vein thrombosis without any significant change.

The admitting diagnoses were left lower extremity DVT, chronic venous insufficiency, fever without signs of cellulitis.  He was restarted on Eliquis ten milligrams (mg) twice a day for seven days and then five mg twice a day.  Plan was to obtain blood cultures. 

The discharge summary indicates that blood cultures showed no growth at one day; patient remained afebrile.  Chest x-ray was within normal limits.  He remained hemodynamically stable. The patient was deemed medically stable and discharged.

This patient was hemodynamically stable on admission. There was no risk of bleeding, or signs of renal insufficiency.  Medical records noted that the patient was unable to fill the prescribed anticoagulation therapy.  However, this could have been provided at a lower level of care.  

The patient was also noted to have fever; however, there was no evidence of sepsis and blood culture was negative. 

In view of the foregoing, the proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End-stage renal disease
Treatment: Skilled Nursing Facility
The insurer denied the Skilled Nursing Facility
The denial is overturned. 

Yes, the continued stay in SNF is medically necessary.

The patient is a female with history of general debility due to end-stage renal disease (ESRD) on hemodialysis. She was admitted to acute hospital due to fluid overload and discharged to a skilled nursing facility (SNF). Related medical issues during admission include GI (gastrointestinal) hemorrhage, iron-deficiency anemia, hypertension, atrial fibrillation, pulmonary edema, bilateral pleural effusions, etc.

Prior to admission, the patient lived alone in an apartment and was independent with all activities of daily living (ADLs).

While the patient was admitted to SNF effective participation was limited due to the incidence of COVID-19 pandemic with restrictive physical contact slowing down the process of rehabilitation. The patient continued to have needs for nursing care for her ESRD, anemia and pulmonary edema with interval episodes of high fever that also limited her effective participation in rehabilitation. She started making progress with increasing rehabilitation.

There was a need for her to continue rehabilitation at the SNF through discharge to continue to make gains in rehabilitation.

Withholding the continued stay in SNF in whole or in part would reasonably be expected to affect the patient's health adversely. The patient was better in continued rehabilitation towards her needs as stated and to be able to return home because she lived alone and was independent prior to admission.
Appeal type: Medical necessity
Decision: Upheld

Mental Health
Mental Health: Inpatient

Diagnosis: Depression. 
Treatment: Inpatient Behavioral Health. The insurer denied the continued inpatient behavioral health stay. The health plan's determination is upheld. 

The patient is a male with a request for continued stay in a behavioral health hospital admission. The patient was admitted due to acute depression, passive suicidal ideation, anxiety, self injury and poor activities of daily living (ADL). As of the date in quesiton, the patient was oppositional. The patient did not want to get out of bed in the morning, but did shower with prompting. The patient was noted to have relationship difficulties with mom. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The patient was medication compliant. The patient was diagnosed with Severe major depression, single episode, without psychotic features.

The Continued Stay in a Behavioral Health Hospital Admission was not medically necessary. The patient was intermittently oppositional, needed prompting to go to school and attend to ADLs. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The patient was medically stable. The patient was not an imminent risk to self or others. Treatment could have been addressed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history of hepatocellular carcinoma, cirrhosis, pleural effusion, seizure disorder, bipolar disorder, hepatic encephalopathy, dependence on supplemental oxygen and weakness who had assessment tool for personal care assistant (PCA) services performed  and was approved for 18 hour/week. There was an appeal to increase PCA services hours to 30 hours/week which was denied by insurer. The patient was hospitalized with ascites, edema and pleural effusion. The patient was not felt to be candidate for further treatment of hepatocellular carcinoma and due to this and complications from end stage cirrhosis was discharged to home on hospice. The discharge summary from the hospitalization documents the need for increased home services. The patient's oncologist wrote a letter to the health plan noting the need for increased PCA service hours due to patient's weakness, fatigue, difficulty with ambulating (using rolator walker), forgetfulness, need for help with meal preparation and medication reminders. This letter specifically requested and increase in PCA hours to 60 hours/week. The patient's hospice and palliative care provider wrote a letter to insurer noting the patient needed an increase in PCA service hours Monday through Friday, to total 50 hours/week. The health plan denied increase personal care assistance services 6 hours per day, 5 days per week - total of 30 hours per week.

The patient had a significant change in his health status from the previous assessment tool. There was a request for an increase in PCA hours in, but since that time the patient had further decline in his health status following hospitalization.  During this hospitalization the patient was deemed appropriate for hospice. According to his oncologist and palliative care physician the patient had increased pain, forgetfulness and fatigue making it difficult for him to ambulate, manage medications, prepare meals, bathing, locomotion, walking and personal hygiene. From the previous assessment tool, the patient was assessed at limited assistance for most of these tasks and based on worsening medical condition and with anticipated deterioration of health (on hospice) assistance will be at least maximum and possibly total.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right leg cellulitis

Treatment: Acute inpatient stay

The insurer denied coverage for acute inpatient stay. The denial is reversed. 

This patient is a male with past medical history significant for hypertension, coronary artery disease, status post stent, status post myocardial infarction, and previous cellulitis several months ago. The patient presented to the Emergency Department (ED) with complaints of fever, right leg erythema, pain, and swelling. The patient's vitals on presentation included: Temperature-102.4 F, Blood Pressure-152/85, Pulse-98, Respiratory Rate-18, and Oxygen (O2) saturation-97%. The patient's laboratory values were notable for the following: white blood cell (WBC) count-9.8, hemoglobin (Hgb)-15.8, hematocrit (Hct)-48.0, creatinine-1.2, and glucose-163. The patient was admitted for possible right leg cellulitis, and was started empirically on antibiotics (cefazolin and doxycycline). The patient's ultrasound Doppler of right leg was negative for thrombus. The patient's x-ray of tibia/fibula showed soft tissue swelling but no evidence for osteomyelitis. The patient's blood cultures were negative. The Infectious Disease (ID) was consulted, and they recommended antibiotic adjustments for the patient. The patient improved clinically, remained afebrile and hemodynamically stable.  The patient was discharged home with instructions to continue oral antibiotics as an outpatient. 

According to the review of the medical records provided, the patient presented with right leg cellulitis.  On presentation, the patient was febrile (temperature of 102.4 F) and hypertensive (blood pressure of 152/85. The patient's laboratory results showed an elevated blood glucose level of 163. Based on the literature review, this patient presented with risk factors that warranted inpatient level of monitoring and care. The patient's history of cellulitis for several months prior and the diabetes indicate that this patient's presenting diagnosis of cellulitis could be complicated without inpatient monitoring and care. Thus, inpatient admission was medically necessary to safely monitor and treat this patient's medical condition.

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 is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class III canines, maxillary spacing and mandibular crowding, and anterior crossbite

Treatment: insertion of braces (comprehensive orthodontic treatment)

The insurer denied coverage for insertion of braces (comprehensive orthodontic treatment). The denial is upheld. 

This patient is a female who presented to the for an orthodontics evaluation.  Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to Class III canines, maxillary spacing and mandibular crowding, and anterior crossbite. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September I, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. However based on the review of this medical record, this automatically qualifying condition criterion was not met for this patient as there was no evidence of gingival attachment loss or gingival recession. The patient's HLD index was calculated and was noted to have a sum of 13 points (2 points overjet, 3 points overbite 5 anterior crowding and 3 points labiolingual spread). Literature shows good evidence that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. This patient's index of 13 points and the clinical circumstance did not meet the clinical criteria for comprehensive orthodontic care. Thus, the insertion of braces (comprehensive orthodontic treatment) was not medically necessary.  

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

The carrier's denial of coverage for the insertion of braces (comprehensive orthodontic treatment) is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory failure, adult respiratory distress
syndrome
Treatment: Continued acute rehabilitation admission 
The insurer denied the Continued acute rehabilitation admission.
The denial is upheld.

The continued acute rehabilitation admission was not medically necessary.

The patient is a male with history of mild intermittent asthma and history of vaping. The patient was admitted to the pediatric intensive care unit with respiratory failure secondary to pneumonia due to mycoplasma and adult respiratory distress syndrome. The patient required mechanical ventilation and IV (intravenous) steroids with sedation for two weeks. 

Following acute care stay and clinical improvement, the child was transferred to rehabilitation facility for inpatient care at the specialty care treatment center for children with medically complex issues. Later, clinical records note that the child was able to ambulate 500 feet without assistive device and was able to negotiate two flight of stairs. The patient was discharged home with outpatient therapy orders. 

Based on the review of clinical records, this child was ready for discharge as of the dates under review.  Clinical records do not support medical necessity for continued acute inpatient rehabilitation stay. Clinical records do not support the need for 15 hours per week of intensive rehabilitative interventions; the child had achieved functional goals. There is no evidence of any specific and extenuating circumstances that required extension of the child's stay in the inpatient rehabilitation unit.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbosacral Degenerative Disc Disease
Treatment: Intracept Procedure
The health plan denied the Intracept Procedure
The determination is upheld.

This is a patient with chronic low back pain. She reported low back pain and bilateral leg pain with tingling in feet. The pain was described as dull, aching, throbbing pain with "stiffness in the lower back, with occasional sharp pain down posterior legs."At issue is whether the proposed health service or treatment Intracept Procedure: Intraosseous Basivertebral Nerve Ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

It is not likely to be more beneficial than any standard treatment or treatments in this specific case. While magnetic resonance imaging (MRI) of the lumbar spine was significant for degenerative changes it was significant for a superimposed left central and subarticular disc protrusion. When the patient saw her physician, she reported low back pain and bilateral leg pain with tingling in feet. The pain was described as dull, aching, throbbing pain with "stiffness in the lower back, with occasional sharp pain down posterior legs." Straight leg raise on the right noted ipsilateral hamstring stretching discomfort "and well as tingling in the foot." Also with ipsilateral hamstring stretching discomfort with straight leg raise on left. The physical exam also noted  extensor hallucis longus (EHL) strength was 4/5, bilaterally, while 5/5 in other muscles of lower extremities. The treatment plan was bilateral sacral (S) 1 transforaminal epidural steroid injections, which is appropriate considering radicular leg pain with positive straight leg raise and associated weakness in EHL combined with noted MRI findings above. It is unclear why the Intercept procedure is being requested. Her provider noted that "Treatments such as transforaminal epidural steroid injections to address any component of discogenic pain and sacroiliac joint steroid injections to address a component of sacroiliac dysfunction have been discussed as measures to provide temporary relief while awaiting intervention for treatment of her vertebrogenic pain." Despite the treatment plan, and the statement above, this reviewer did not see any procedures notes stating these procedures occurred nor follow-ups noting what type of relief the above procedures provided. The patient has low back pain with a radicular component - which is not what the Intracept procedure is meant to treat; radicular pain was exclusion criteria for the study noted in "Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study." Therefore, in this specific case, the Intracept procedure is not likely to be more beneficial than standard treatment.

The determination is upheld in whole.