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

Diagnosis: Dementia, psychosis and severe anxiety/depression.

Treatment: 168 hours/week Personal Care Aide to offer increased ADL (activities of daily living).

The insurer denied the 168 hours/week Personal Care Aide to offer increased ADL (activities of daily living).

The denial is overturned. 

The patient is a female with a history of dementia, psychosis and severe anxiety/depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 168 hours/week Personal Care Aide to offer increased ADL (activities of daily living) support.

Yes, the requested increase in Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift) is medically necessary.
The patient is a female with a history of dementia, psychosis and severe anxiety/depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and noted that the currently approved plan of 56 hours/week is sufficient to meet the patient's current needs, the patient's medical provider reports that this reduced schedule leaves her home alone, completely unassisted for numerous hours/day. This is problematic, as she requires constant supervision to help with toileting, changing of dirty incontinence diapers, sheets, frequent bed repositioning/turning to prevent pressure ulcers and assistance with transfers and ambulation to prevent potential fall injury.

Hence, provision of Personal Care Aide 168 hours/week split-shift can reasonably be expected to be beneficial for the patient, and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 168 hours/week Personal Care Aide is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infection, dental cleaning
Treatment: D4341 - Deep Gum and Root Cleaning (Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant, Upper Right Quadrant)
The insurer denied the D4341 - Deep Gum and Root Cleaning (Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant, Upper Right Quadrant).
The denial is overturned. 

The patient is a male requesting dental benefits for deep gum and root cleaning (D4341) for all four quadrants of his mouth. Periodontal charting, x-rays, and consultation were completed on the patient.

The health plan is denying the claim because they state that they do not see hard tartar build up on the roots and they do not see bone loss when the x-rays were viewed.

The patient is appealing because of the severity of the infection he has endured and the fact that he has been diagnosed and treated for gum disease for quite sometime.

Yes, the proposed treatment of deep gum and root cleaning is medically necessary.

As is evident on the x-rays and as noted by the provider on the periodontal charting report, the patient does exhibit bone loss in several areas, especially around the premolar and molar regions. Once the bone levels are reduced, this creates a pocket between the teeth that makes it more difficult to clean and keep bacteria at a minimum. Therefore, there is the tendency for the patient to develop inflammation and infection in and around the gums. The proposed treatment of deep gum and root cleaning is medically necessary.

The issue of gum disease is a very serious one. If left untreated, the complications can have far reaching effects on the patient's overall health.

Studies show the link between gum disease and several comorbidities such as type II diabetes, cardiovascular disease, hypertension, stroke.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Elevated troponin level

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is overturned. 

This female patient has a history of asthma, hypertension (HTN), obesity and medication noncompliance.

Hypertensive emergency is defined as blood pressure greater than 180/120 with target organ damage.1 This patient had an elevated high sensitivity troponin level consistent with myocardial injury and target organ damage. Acute renal insufficiency was also noted. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing rapid blood pressure correction.2 Given this patient's failure to respond to initial medical therapy, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the intensive care unit for management of hypertensive emergencies1. In conclusion, this patient should have been managed at a higher 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 inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Pain and Shortness of breath.
Treatment: Inpatient admission.
The insurer denied the Inpatient admission.
The denial is Upheld.

The patient is an adult male with a past medical history significant for HTN (hypertension), dyslipidemia, obesity, alcohol abuse, sleep apnea, on CPAP (continuous positive airway pressure), pulmonary embolism on anticoagulation with Xarelto, schizoaffective disorder, and recent admission for alcohol withdrawal. He presented to the ER (emergency room) with complaints of leg pain and shortness of breath.

The patient was hemodynamically stable. ECG (electrocardiogram) revealed no acute ischemic changes. Chest X-ray revealed cardiomegaly and increased interstitial markings. Patient had a negative test for COVID-19. Doppler study was negative for DVT (deep venous thrombosis). The patient was given a dose of Lasix in the ER (emergency room) and admitted for suspected CHF (congestive heart failure).

The patient's BNP (brain natriuretic peptide) was low. There was no evidence of alcohol withdrawal. Patient had an echocardiogram, which revealed normal LV (left ventricle) systolic function and normal EF (ejection fraction). The patient was continued on his home medications. He was discharged home with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.
The patient presented for evaluation of leg pain and dyspnea. Cardiac enzymes were negative with no evidence of myocardial infarction or injury. The patient was treated with a dose of Lasix in the ER (emergency room) and was not evidenced to be fluid overloaded on exam. Echocardiogram revealed preserved LV (left ventricle) function. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), malignant arrhythmia or hemodynamic instability. BNP (brain natriuretic peptide) was low. There was no evidence of DVT (deep venous thrombosis) on Doppler study. There was no evidence of alcohol withdrawal. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Nausea and Vomiting.
Treatment: Inpatient Hospital Admission.
The insurer denied the Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male patient who had presented again to the emergency department of the facility filing the appeal.  The patient had reported nausea and emesis with one day of coffee ground emesis. The patient had several prior presentations for nausea and emesis in the preceding week. The patient had a history of gastritis and obesity. An evaluation, including ultrasound and laboratory values, was unremarkable. The patient was admitted for supportive care. The patient underwent a completely normal endoscopy. The patient was then discharged once deemed stable.

No, the proposed treatment was not medically necessary.  The care as provided was medically appropriate but the level at which the care was delivered was not medically necessary.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had recurrent nausea with emesis, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring, severe electrolyte dyscrasias or any other indication for an acute admission.  The endoscopy does not require inpatient level of care and could have been provided at a lower level of care. The evaluations were normal. As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eosinophilic esophagitis, and chronic abdominal pain
Treatment: Actiq (fentanyl citrate oral transmucosal lozenge)
The insurer denied the Actiq (fentanyl citrate oral transmucosal lozenge).
The denial is overturned.

Yes, the requested Actiq is medically necessary. 

The patient is an adult male with eosinophilic esophagitis, and chronic abdominal pain in whom Actiq has been recommended.  The patient was on Fentora for many months and was doing well.  He has an ITP (intrathecal pump) as well.  He does not tolerate oral medications very well.  He is tolerating oral hydromorphone, but is taking quite a bit of this.  The patient is cachectic, based on the PE (physical examination) from the attached documentation.  The patient does not oral intake well due to the pain related to the esophagitis.  He was doing much better with the Actiq, or Fentora that allowed him to eat better, and gain weight.  The patient does have a high MED (morphine equivalent dosage), and all alternative routes of medication have failed, including IT (intrathecal), transdermal, and oral.  Given that the patient was tolerating the Actiq, and prior to this Fentora, the patient is not opiate-naive, the patient is losing weight and at risk for failure to thrive without it, the requested Actiq is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain.
Treatment full admission and hospital care.
The insurer denied coverage for full admission and hospital care.
The denial is upheld.

This is the case of an adult male that presented to the hospital complaining of several seconds of left sided chest pain that occurred 3-4 times over the course of a day. Past medical history was significant for Prinzmetal angina and anxiety. Upon arrival to the hospital, vital signs were stable with blood pressure (BP) of 143/60 and pulse 58. Physical exam was without abnormality. Electrocardiogram (EKG) revealed sinus bradycardia with T (interval on EKG) wave inversions in lead III. Serum troponin was 0.1 nanograms/milliliter (ng/ml) and trended downward to 0.07 ng.ml. Echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) with left ventricular hypertrophy and no significant wall motion abnormalities. The patient was admitted to the hospital for monitoring and treatment and discharged the following day with follow up.

This patient presented with atypical chest pain and nonspecific findings on EKG. His pretest probability of coronary artery disease is low to intermediate. (1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score he was considered low intermediate risk (3 points). (2) Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on EKG was reviewed by Hedayati et al. (3). Using the HEART score risk stratification schema, this patient would have a low 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. The positive troponin levels are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (4,5) They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. (5) Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.

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

The insurer's denial of coverage for full admission and hospital care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is an adult male with history of prostate cancer and hypertension. The patient presented to the hospital for a scheduled robotic-assisted laparoscopic prostatectomy (RALP). The procedure was performed without complication. The patient was then admitted for post-operative care. He was tolerating a regular diet, oral medication, voiding, and was ambulatory. Deep vein thrombosis (DVT) prophylaxis was provided. The Jackson-Pratt (JP) drain was removed prior to discharge. The patient was deemed stable for discharge home.

The insurer has denied coverage for the inpatient admission as not medically necessary. They noted a lack of severe findings that would warrant an inpatient admission. The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guideline (MCG) Health (24th) Prostatectomy, Radical and MCG Health (24th) Urologic Surgery or Procedure, General Recovery Care (GRG), the patient appears to meet the admission to Inpatient Care discharge parameters within 24 hours post-procedure to satisfy to satisfy MCG Prostatectomy, Radical and meets the GRG discharge parameters within 24 hours post-op to satisfy MCG Urologic Surgery or Procedure. The goal length of stay for this procedure is 1-day post-op. The patient appeared to have a smooth, uneventful post-op course without complications; received quite expeditiously.

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

The inpatient admission was not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anorexia nervosa

Treatment: inpatient mental health services

The insurer is denied coverage for inpatient mental health services

The denial is overturned. 

This female patient has a history of constipation, gastroparesis, seizure disorder and anorexia nervosa.

Anorexia nervosa has a high mortality rate if untreated and is a chronic and difficult disorder to treat. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders reports that patients that need supervision at all meals need 24-hour inpatient treatment. It also states that patients with acute weight decline with food refusal, preoccupation with intrusive repetitive thoughts, NG tube placement, or being uncooperative while in a highly structured environment need inpatient treatment.
The medical records provided enough specific evidence to support that she required at least this level of care. The patient had continued difficulty with both severe eating disorder symptoms and depressive symptoms including suicidal thoughts with plans to jump in front of traffic if not in this 24-hour setting. During the denial period she had poor meal compliance and severe malnutrition with inability to restore weight.  There were also reports of physically aggressive behavior including attacking staff. 
The patient lost 5.8 pounds and had a body mass index (BMI) as low as 14.66. She continued to refuse oral intake at times, continued to hide and crumble food, refused the request for nasogastric (NG) tube placement, and eventually had involuntary tube feedings. The patient also had poor activities of daily living (ADLs), and would not get out of bed at times to eat breakfast. She reported suicidal ideation and plans to jump into traffic if discharged. She was considered a high suicide risk due to multiple past suicide attempts including Tylenol overdose and running into traffic and she still reported suicidal thoughts and plans. 
She continued to refuse NG tube placement. Notes reported that she had increased suicidal thoughts since involuntary tube feedings. Notes reported that she was transferred to a medical inpatient hospital setting due to severe malnutrition and inability for weight restoration. 
This was a very high risk patient who required this 24-hour inpatient setting until her transfer to a more intensive inpatient medical hospital setting. Without this structured and supervised inpatient setting, she likely would have continued to restrict and lose weight, and compromise herself further both medically and psychiatrically, as she was also a high suicide risk. Based on the above, the continued inpatient mental health services at Walden Behavioral Care were considered medically necessary treatment for the patient's 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 inpatient mental health services is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: memory loss

Treatment: computed tomography (CT), of the head or brain without contrast (dye) for the patient

The insurer is denied coverage for computed tomography (CT), of the head or brain without contrast (dye) for the patient

The denial is overturned. 

This female patient has a history of memory loss, anxiety, and hyperlipidemia

Per Staffaroni, A. M. et al. (2017), "The diagnosis of dementia is becoming increasingly reliant on a broad range of neuroimaging techniques, and this is reflected in several updated diagnostic criteria.1,2 Neuroimaging enhances the accuracy of diagnoses for distinct dementia subtypes. The recent failures of treatment trials for Alzheimer's disease (AD) 3 indicate that earlier intervention, and therefore earlier diagnosis, may be critical to treatment success. Early diagnosis can be facilitated by neuroimaging techniques that can detect the earliest pathological and metabolic alterations that occur in neurodegenerative disease." 

Weller, J. et al. write that, "Building upon the original 1984 diagnostic criteria, the National Institute on Aging Alzheimer's Association (NIAAA) revised the clinical criteria for the diagnosis of mild cognitive impairment (MCI) and the different stages of dementia due to AD in 2011 6 8. The use of supportive biomarker evidence (imaging, serum, and CSF) of AD pathology were included to aid in the delineation of AD from other forms of dementia as well as in the diagnosis of MCI due to AD. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) re-classified delirium, dementia, amnestic and other geriatric cognitive disorders into the more encompassing neurocognitive disorders 9. This change was made to better discriminate between different neurodegenerative diseases, such as AD, dementia with Lewy bodies, and frontotemporal dementia, as well as to include both major neurocognitive disorder (equivalent to dementia) and mild neurocognitive disorder (equivalent to MCI) 4. Finally, the newer criteria allow for the use of current and future biomarkers in the diagnosis of degenerative brain disease." 

As noted in the first question the patient did complain of memory difficulty, and brain imaging is medically necessary in patients with memory loss. The computed tomography (CT), of the head or brain without contrast (dye) considered is medically necessary for this patient.

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 computed tomography (CT), of the head or brain without contrast (dye) for the patient is overturned.  The medical necessity is  substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, Altered mental status.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with a history including MS (multiple sclerosis), chronic pain, hypertension, chronic PEG (percutaneous endoscopic gastrostomy) and foley, and status-post COVID (Coronavirus). He was sent from SICC (Staten Island Care Center) for evaluation of fever and altered mental status. Per records, his chest x-ray showed pneumonia.

In the ED (emergency department), his rectal temperature was 103, and the patient was lethargic. His admission VS (vital signs) were as follows:  Temperature 100.2, heart rate 108, respiration rate 20, blood pressure 122/74, pulse oximetry 95%.  The patient's exam was remarkable for mild distress, dry mucous membranes, wheezing and edema. The patient's labs were as follows:  WBC (white blood count) 12.6, H/H (hemoglobin/hematocrit) 11.8/35.7, Plt (platelets) 366, Na (sodium) 132, K (potassium) 4.3, BUN/Cr (blood urea nitrogen/creatinine) 19/.5. His lactic acid was 1.2. His pH (potential of hydrogen) was 7.45.  The patient's U/A (urinalysis) revealed pH (potential of hydrogen) 8.9, protein, blood, leukocyte esterase, RBC (red blood cells) and WBC (white blood cells).  Chest x-ray revealed no infiltrate.

The patient was admitted with sepsis secondary.  Plan of care included IVF (intravenous fluids) and IV (intravenous) antibiotics.  ID (infectious disease) consult recommended foley change and IV (intravenous) antibiotics.

On day two, the patient's vital signs were stable, and the patient was afebrile.  Clogged PEG (percutaneous endoscopic gastrostomy) tube was relieved by GI (gastroenterology).  Plan was to continue IV (intravenous) antibiotics.

On day three, the patient's vital signs were stable. The plan was to continue IV (intravenous) antibiotics.

On day four, the patient's vital signs were stable.  Blood cultures were negative.  Urine cultures were negative.  The plan was to continue IV (intravenous) antibiotics.  Discharge planning was in progress.

Yes, the Inpatient admission was medically necessary.
The Inpatient admission was consistent with generally accepted national standard of medical practice.

This patient with chronic conditions including MS (multiple sclerosis) and chronic foley was admitted with sepsis. The patient was transferred with altered mental status and fever. In the ER (emergency room), the patient was lethargic with a temperature of 103. He had tachycardia. He was hemodynamically stable. He did not have renal failure. Physical exam was consistent with dehydration. Evaluation revealed UTI (urinary tract infection) as source of infection. Based on this patient's presentation, inpatient admission was appropriate and medically necessary for this patient with an indwelling foley who presented with altered mental status and urosepsis.