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

Diagnosis: Substance Abuse/Addiction
Treatment: Substance Abuse: Inpatient
The insurer denied Substance Abuse: Inpatient
The determination is upheld.

This patient received inpatient level of care for substance use disorders. Diagnoses included alcohol use disorder, cocaine use disorder, and cannabis use disorder. The patient had a history of substance use problems dating back to age 16. The patient had been smoking crack cocaine 4 to 5 days weekly prior to admission and drinking alcohol and smoking cannabis. The patient had a history of overdose on fentanyl laced crack cocaine about one month prior to treatment. 

The patient reported that their family was supportive of them seeking substance use disorder treatment. They have a daughter and two granddaughters. The patient is married. The patient was reported as being motivated for recovery and participatory in various groups and other therapeutic offerings. At issue is the medical necessity of the requested health service/treatment of inpatient admission at the rehabilitation level of care.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.
The patient did not have a life-threatening medical condition or severe psychiatric crisis. The patient clearly met criteria for multiple substance use disorders. The patient was not in full remission from a substance use disorder. The patient did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting. The patient did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting. The patient had used in hazardous situations including using fentanyl laced cocaine. The patient did not need an inpatient rehabilitation setting to safely address cognitive or behavioral impairment leading to substance use. Based on documentation, the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care is: Stabilization Services in a Residential Setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

Asked to review the case of an adult male that presented to the hospital with fever of 101.7 degrees F and symptoms of nausea and vomiting. Past medical history was significant for metastatic pancreatic cancer on chemotherapy, diabetes mellitus, hypertension, coronary artery disease status post right coronary artery (RCA) stent, and pulmonary embolus.  On arrival to the hospital blood pressure was 98/51 and pulse was 78. Physical examination was significant for poor distal pulses on lower extremities and  a second right toe amputation. Electrocardiogram demonstrated sinus rhythm with Q waves inferiorly and nonspecific T wave changes.  Serum blood testing demonstrated several abnormalities: White blood cells (WBC) 18,000 with bandemia, lactate of 2.0, troponin of 240, and B type natriuretic peptide of 3498.  Chest X ray revealed a right lower lung infiltrate. The patient was treated with intravenous antibiotics and admitted to the hospital for ischemia work up and sepsis work up.  Echocardiogram revealed an left ventricular ejection fraction (LVEF) of 55% with mild inferior 
wall hypokinesis and with moderate mitral regurgitation.  The patient was treated medically 
for type II myocardial infarction.  He was ultimately diagnosed with infection due to 
osteomyelitis of the distal extremity and was discharged on antibiotic therapy.

This patient presented with fever, nausea and vomiting and an elevated serum troponin level.  His pretest probability of coronary artery disease was high.(Reference 1)  Utilizing the HEART score (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) he was considered intermediate risk. (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In addition to the issue of an acute coronary syndrome, this patient had multiple medical problems including metastatic pancreatic cancer and possible sepsis.  The patient was ultimately diagnosed with osteomyelitis that likely contributed to a type 2 myocardial infarction. (Reference 4).

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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male child who was taken to the emergency department (ED) via Emergency Medical Services (EMS) after drinking some salt water from the pool and not feeling well. He accidentally swallowed the pool water two days prior, developed intermittent fevers to 101 degrees one day prior associated with chills, constant aching abdominal pain rated 5/0, and sore throat. There was no vomiting or diarrhea. The examination was significant for chills, no apparent distress, clear oropharynx, clear lungs, tachycardia, non-tender abdomen with no distention, and non-focal neurologic exam. An abdominal ultrasound did not reveal the appendix but revealed increased cortical echogenicity of the right kidney suggestive of renal parenchymal disease and possible pyelonephritis. A computed tomography (CT) scan of the abdomen and pelvis revealed mild constipation, slight apparent thickening of the terminal ileum/ileocecal valve suggestive of inflammatory or infectious ileitis, appendix filled with enteric contrast but with some mild possibly related wall thickening of unknown significance. He was treated with a normal saline bolus and ibuprofen. Surgery was consulted with recommendations for supportive care and no surgical intervention. He was admitted for further management.
Admission orders included gastrointestinal (GI) polymerase chain reaction (PCR), Giardia panels, inflammatory lags, antipyretics, maintenance intravenous (IV) fluids, and consideration for antibiotics. GI polymerase chain reaction (PCR) was positive for Norovirus. Blood work was significant for C-reactive protein (CRP) 26.15, procalcitonin 3.87, erythrocyte sedimentation rate (ESR) 5, lactate normal. He did well overnight with improved pain, he was able to eat without nausea, and he had no fever. His examination improved and was significant only for mild right lower quadrant tenderness. He was deemed stable for discharge home. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary. 

This male child presented with a fever and abdominal pain. His diagnostic evaluation in the ED was relatively non-specific, but a gastrointestinal (GI) PCR was positive for Norovirus. While it was not unreasonable to monitor him overnight in the ED for deterioration versus resolution of pain as well as ability to tolerate adequate fluids, he was overall hemodynamically stable with no vomiting or diarrhea, no evidence of peritonitis or obstruction, and no significant metabolic abnormalities. He did not require acute inpatient admission and could have been managed safely at lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cervical Stenosis
Treatment: Total Disc Arthroplasty
The insurer denied: Total Disc Arthroplasty
The denial is: Overturned

The patient is a male with neck and radicular arm pain with cervical magnetic resonance imaging (MRI) showing cervical (C)5-6 stenosis and failure of physical therapy (PT) and medical management. The patient was recommended C5/6 disc replacement which was denied by his health plan as not standard of care. The subject under review is whether the total disc arthroplasty is likely to be more beneficial for this patient than any standard treatment.

The recommended procedure of total disc arthroplasty is likely to be more beneficial than other standard options for this patient.

The patient has left arm pain which has affected his activities of daily living (ADLs). The patient has tried non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, gabapentin, and injections. He has also tried physical therapy (PT). The patient has failed these options. Cervical disc replacement is Food and Drug Administration (FDA) approved, there are no current trials noted, and no further studies are needed. The requested procedure is well studied and likely to be more beneficial than standard anterior cervical discectomy and fusion (ACDF) treatment options for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cervical Stenosis
Treatment: Total Disc Arthroplasty
The insurer denied: Total Disc Arthroplasty
The denial is: Upheld

The patient is a male with a history of left arm pain. He has had physical therapy, injections and medications without relief. He is a non-smoker. The neurologic exam shows 4/5 left biceps strength. The cervical magnetic resonance imaging (MRI) shows a herniated disc at cervical (C)5-6 left with severe stenosis. The provider has recommended a C5-6 total disc arthroplasty (TDA) with Mobi-C.

The procedure is not likely to be more beneficial than any standard treatment for the herniated cervical disc. However, by the current literature it would be equal or comparable to the standard anterior cervical discectomy and fusion procedures. The patient clearly has surgical indications for his radiculopathy, and a TDA or anterior cervical discectomy and fusion (ACDF) would be appropriate.

In a study looking at cervical fusion and artificial disc placement, Phillips et al. cite "he long-term results show good clinical outcomes after ACDF and Porous Coated Motion (PCM) arthroplasty". Other authors discuss cervical arthroplasty as a good alternative to cervical fusion. Sasso et al. cite "at 7 and 10 years, cervical arthroplasty compares favorably with ACDF as defined by standard outcomes scores in a highly selected population with radiculopathy". Hisey et al. cite, "Five-year results demonstrate the safety and efficacy of TDR with the Mobi-C as a viable alternative to ACDF with the potential advantage of lower rates of reoperation and adjacent segment degeneration, in the treatment of one-level symptomatic cervical degenerative disc disease".
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cervical Stenosis
Treatment: Total Disc Arthroplasty
The insurer denied: Total Disc Arthroplasty
The denial is: Overturned

The patient is a male with months of left arm pain radiating into the hand in a cervical (C)6 distribution. Physical exam is notable for positive (+) Spurling's, 4/5 left (L) biceps and wrist extensors, and decreased sensation in C6 distribution. Cervical magnetic resonance imaging (MRI) demonstrated severe cervical (C)5/6 central stenosis due to disc osteophyte complex, disc herniation and congenitally small canal. Cervical x-rays showed minimal disc degeneration at C5/6 with loss of lordosis. Prior treatments included physical therapy (PT), non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, muscle relaxers, and injections. Despite conservative management, his symptoms were affecting his activities of daily living. The patient was recommended C5/6 disc replacement which was denied by his health plan as not standard of care. The subject under review is whether the total disc arthroplasty is likely to be more beneficial for this patient than any standard treatment.

The recommended C5/6 total disc arthroplasty is likely to be more beneficial than continued non-surgical management which the patient has already failed, as well as cervical fusion. As outlined in the provided supporting documentation, cervical disc replacement is Food and Drug Administration (FDA) approved has been shown to decrease the incidence of adjacent segment disease and rate of revision surgery at the index level, increase the range of motion, and decrease the time to return to work compared to anterior cervical discectomy and fusion (ACDF) surgery.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: ADHD. 
Treatment: Vyvanse. 

The health plan denied formulary exception for Vyvanse. The denial is upheld. 

The patient is a male child diagnosed with ADHD (attention-deficit hyperactivity disorder). He has tried and failed amphetamine/dextroamphetamine. 

The patient is not documented to have tried and failed the formulary alternatives. No justifiable rationale was provided as to why the patient cannot be tried on the alternatives, which are reasonably expected to be just as effective as Vyvanse. 

Therefore, the health plan should not cover the formulary exception for Vyvanse.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Live In)
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Live In).
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for dementia, incontinence, gait abnormalities, and Parkinson's disease. The patient and her care team requested an increase to 24 hour per day (live-in) personal care and this request was denied by the health plan. This denial is the subject under review.

The patient's physician provided a letter of support for this appeal. The letter states that the patient requires a one person physical assist for all activities of daily living. She is incontinent of stool and urine and requires a 1 person physical assist for toileting and bathing. She requires assistance with transfers and for twice daily walk with assistance as tolerated. She lives alone and has no informal support. Therefore, the physician requests that the patient receive the requested increase in personal care to meet her needs.

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Live In) is medically necessary for this patient.

The patient has dementia, incontinence, and gait dysfunction with wheelchair bound status. She requires hands-on assistance from others for all activities of daily living (ADL) and Instrumental activities of daily living (IADL) including toileting and transfers. Her personal care needs cannot be managed in a specified time block each day given that her needs can be reasonably expected to be continuous and unscheduled. She will require intermittent toileting, changing, and repositioning assistance throughout the daytime and on occasion at night as well. The increase in personal care to 24-hour live-in is medically necessary and appropriate for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility
Treatment: Intracytoplasmic Sperm Injection (ICSI)
The insurer denied the Intracytoplasmic Sperm Injection (ICSI).  The denial has been overturned. 
The proposed treatment is medically necessary.

The patient is a female requesting coverage for intracytoplasmic sperm injection (ICSI) and was denied because it is approved when there is a male factor infertility as documented by at least two abnormal semen analysis within the past three months.  The patient has a diagnosis of infertility and has failed multiple inseminations.  The provider stated that the semen analysis was abnormal as it showed decreased motility and decreased normal morphology. Therefore, there is need for intracytoplasmic sperm injection (ICSI).

The patient has a diagnosis of infertility.  Multiple semen analyses have shown a decrease in motility and a decrease in normal morphology necessitating in vitro fertilization.  Note that performing in vitro fertilization without intracytoplasmic sperm injection (ICSI) may have resulted in poor fertilization necessitating a second invitro fertilization (IVF) cycle.  Based on the semen parameters that were submitted and the medical history of the couple, intracytoplasmic sperm injection (ICSI) is medically necessary.       

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

Specifically, the patient has repeatedly abnormal semen analysis and intracytoplasmic sperm injection (ICSI) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

Asked to review the case of an adult patient that presented to the hospital complaining of shortness of breath. Past medical history was significant for hypertension, diabetes mellitus, and systolic congestive heart failure with a left ventricular ejection fraction of 25-30% (percent). On arrival to the hospital the patient was hypertensive with a Blood Pressure (BP) of 181/129 and a pulse of 115.  Physical examination revealed bilateral wheezing on lung exam and abdominal distension without rebound or tenderness.  12 lead electrocardiogram (EKG) revealed sinus tachycardia with atrial premature contractions (APCs) and left ventricular hypertrophy.  Serum blood testing revealed acute renal insufficiency with creatinine of 1.9 and an elevated high sensitivity troponin level of 113. Urine toxicology was positive for cocaine. The patient was treated with bi-level positive airway pressure (BiPAP) mask, intravenous nitroglycerin and furosemide therapy but remained hypertensive.  He was scheduled for admission to the hospital for additional treatment but left the emergency department (ED) against medical advice. 

Hypertensive emergency is defined as BP (blood pressure) >180/120 with target organ damage. (Reference 1) This patient presented with a systolic BP of 181. His Troponin and B type natriuretic peptide (BNP) levels were elevated consistent with left ventricular target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Admission to the hospital for aggressive blood pressure management was necessary in this case. In fact, American Heart Association guidelines recommend admission to the ICU (intensive care unit) for management of hypertensive emergencies (Reference 1). In conclusion inpatient admission was medically necessary.

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 inpatient Hospital Admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphoma
Treatment: Full hospital admission
The insurer denied the full hospital admission.  The denial has been upheld. 

The proposed inpatient hospital admission was not medically necessary.

The patient is a female with newly diagnosed mantle cell lymphoma.  She was admitted to the hospital to complete work-up of her lymphoma, initiate chemotherapy and control her diabetes mellitus (DM).  The patient was started on allopurinol and insulin.  The patient underwent bone marrow biopsy.  Her bone marrow was non-diagnostic. The patient was placed on chemotherapy on for two days.  On the next day, the patient developed a fever.  Her blood sugar (BS) remained poorly controlled and rituximab was considered.  The patient was given rituximab.  The patient remained with hypertension (HTN) and tachycardia with poorly controlled blood sugars.  This persisted on for two days and she was discharged with patient follow-up.

This patient was admitted for "expedited" work up of her lymphoma, yet the bone marrow biopsy was delayed.  This patient had clinically diagnosed lymphoma since the beginning of the month and there was no reason to delay bone marrow biopsy.  This could have done prior to when it was completed as an outpatient or when the patient was initially admitted. 

In addition, some of the other hospital days were not necessary.  The patient had completed chemotherapy and was stable.  Her blood pressure remained poorly controlled as well as her diabetes mellitus but these were not new issues and she was essentially at baseline.  Further management of her diabetes mellitus and hypertension did not require inpatient hospitalization to manage and she could have been managed on an outpatient basis.

There is no basis to hospitalize a patient with chronic issues such as diabetes mellitus or hypertension that are poorly controlled.       

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

Diagnosis: Congestive heart failure (CHF), Parkinson's disease, osteoarthritis, chronic kidney disease (CKD), gastroesophageal reflux disease (GERD), hyperlipidemia, and diabetes. 
Treatment: Home Care / Personal Care HHC (home health care) - 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 overturned. 

This is an elderly female with chronic medical problems including Parkinson's disease, heart failure and kidney disease. She lives alone in a 1 bed apartment of a senior citizen building. The insurer approved home care / personal care HHC - level 2 personal care services, per 15 minutes, increase to 84 hours/week and the request is for home care / personal care HHC - level 2 personal care services, per 15 minutes, increase to 24 hours per day (live in). 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as moderately impaired. She is reportedly totally dependent to maximal assistance for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She reportedly requires maximal assistance for bathing, personal hygiene, dressing, locomotion and toilet transfer.  She is totally dependent for toilet use and non-ambulatory. Extensive assistance is reportedly needed for bed mobility and eating. The patient is reportedly occasionally incontinent of bowel and bladder. 

The patient's Activities of Daily Living (ADL) status has declined and there have been no reported falls over the prior 90 days. Given the patient's reported cognitive deficits and general debility, she may benefit from additional physical needs and safety monitoring.  Based on the records reviewed, a live-in PCA (personal care aide) is medically necessary and the currently approved PCA 12 hours/day, 84 hours/week is not an appropriate level of service to address the patient's functional needs. 

From a physical medicine and rehabilitation perspective, home care / personal care HHC - level 2 personal care services, per 15 minutes, increase to 24 hours per day (live in) is medically necessary. 

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 home care / personal care HHC - level 2 personal care services, per 15 minutes, increase to 24 hours per day (live in) services is substantiated.