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

Diagnosis: Dementia, heart failure, dyspnea, pacemaker, high blood pressure, diabetes, and palpitations
Treatment: Personal Care Assistance (PCA) Services - 84 hours/week
The insurer denied the PCA services - 84 hours/week.
The denial is upheld.

This elderly female has several conditions including dementia, heart failure, dyspnea, pacemaker, high blood pressure, diabetes, and palpitations. She lives alone. Denial of personal care assistance (PCA) services - 84 hours/week is being appealed. She currently receives 56 hours/week. Uniform Assessment System (UAS) evaluation completed nearly a year ago shows moderate impaired condition and functional status: total dependence with meal preparation, housework, shopping, and transportation; maximal assistance with managing finances and medications, phone use, bathing, and lower body dressing; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. She has bowel and bladder incontinence. The statement from the provider notes the member has declined functionally and cognitively over the past year. She was found by neighbors wandering in the absence of the HHA (home health aide). She tries to cook in the absence of the HHA. She ambulates with a rolling walker. She is dependent with transfers and ADLs (activities of daily living). She has a history of falls in the absence of the HHA.

The proposed treatment is not medically necessary.

PCA Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. The member has multiple chronic conditions. Denial of PCA services - 84 hours/week is being appealed. She currently receives 56 hours/week. The plan reported that personal care tasks can be done in the time currently provided and additional hours would be for stand-alone safety supervision. UAS evaluation completed nearly a year ago shows moderate impaired condition and that she needs assistance with all ADLS, except bed mobility and eating. A statement from her provider notes she has declined functionally and cognitively over the past year. She has been found wandering and attempting to cook in the absence of the health aide. Based on this information, additional hours are being requested for supervision. 

PCA services are not indicated for supervision and when no tasks are being performed. The proposed increase in PCA services to 84 hours/week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient stay.

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

The patient is a woman, who presented with abdominal pain, nausea and vomiting of 1-day duration. At the time of presentation, the patient was without fever, heart rate was 105/minute, and blood pressure was 141/104. She was tender in the right upper quadrant. The white blood cell count was elevated at 18.9. The complete metabolic panel identified elevated liver enzymes (alanine aminotransferase (ALT) of 125 and aspartate aminotransferase (AST) of 269) and normal bilirubin. Serum lipase was elevated. Ultrasound and computed tomography (CT) scan showed a distended gallbladder with gallstones and no ductal dilatation.

An inpatient level of care was not medically necessary in this case. This patient presented with abdominal pain of 1-day duration. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. While the initial white blood cell (WBC) count and serum transaminases were elevated, they promptly normalized. The progress notes state that the patient was stable for discharge from the hospital on the first post-surgical day. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure, Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient with a history of end stage renal disease (ESRD) on hemodialysis, coronary artery disease (CAD), hypertension (HTN), peripheral artery disease (PAD), and aortic stenosis status/post (s/p) transcatheter aortic valve replacement (TAVR) who presented to the hospital with the sudden onset of shortness of breath which was severe and worse when lying flat. He denied nausea, vomiting, fevers, neck pain, chest pain, or chills. Emergency Medical Services (EMS) reported an initial room air oxygen saturation of 83 percent (%); he was given albuterol and nitroglycerin with some relief. On exam, he was in no apparent distress with clear breath sounds bilaterally. An electrocardiogram (EKG) was unremarkable. A chest x-ray showed mild congestive changes. He was admitted for further workup and evaluation of congestive heart failure (CHF). Nephrology was consulted and arranged for dialysis that day. He underwent dialysis with improvement in his symptoms. He was discharged home in stable condition. At issue is the medical necessity of an inpatient hospital stay.

The inpatient stay was not medically necessary based on the documentation provided. The patent presented with shortness of breath. He was found to be hypoxic on initial presentation but improved expectantly with medical therapy in the emergency room and dialysis treatment. He did not have respiratory distress that persistent despite dialysis or emergency room measures. He did not have cardiac arrhythmias. He did not have severe metabolic or electorally abnormalities. He did not have uremic pericarditis, encephalopathy or bleeding. There was no other clinical indication that required inpatient management or monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient who initially presented to the emergency department (ED) with the complaint of abdominal pain for 1 day. He was evaluated in the ED and a non-operative treatment plan was elected. He returned to the ED with persistent right lower abdominal pain. His white blood cell (WBC) count had been 16.6 thousand (K) and a computed tomography (CT) scan identified findings of early appendicitis. The examination revealed right lower abdominal tenderness. The vital signs identified an elevated blood pressure at the time of presentation. The WBC count was 6.9 K. A surgical consultation was obtained. The patient underwent a laparoscopy with appendectomy for the condition of appendicitis. The operative dictation describes an inflamed appendix. Following surgery, the patient was treated with intravenous (IV) fluid, antibiotics, and analgesia. The patient's vital signs were consistently normal in the perioperative period. He was discharged from the hospital following an initial period of recovery.

At issue is the medical necessity of an inpatient hospital stay.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated without the need for a full inpatient admission.

This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan supported the diagnosis of acute appendicitis at that time. It was opted to treat with antibiotics. The patient returned to the hospital with persistent right lower abdominal pain and tenderness. The diagnosis and indication for surgery was established. He underwent an uncomplicated appendectomy. Following surgery, he was clinically stable and was tolerating a diet. The pain medications were transitioned to oral medications. He was discharged from the hospital.

The patient was clinically stable at the time of presentation and remained so during the course of care.  A lower level of care would have provided for pre-surgical assessment, operative treatment and post-surgical monitoring and antibiotics. This lower level of care would have also allowed for overnight monitoring (if needed).

The records include Milliman Care Guidelines (MCG). These criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the procedure may be performed without an inpatient hospital admission. In this case, the patient tolerated oral hydration, a diet and medication and the pain was well controlled. A lower level of care would have appropriately provided for pre-surgical assessment, laparoscopic appendectomy, and post-surgical monitoring, provision of antibiotics and pain medications. Inpatient care was not required or medically necessary in this case per the referenced MCG or generally accepted medical standards.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

This is a male patient who presented to the emergency department (ED) with complaints of abdominal pain for 1 day. He had a known history of gallstones. The comorbid health conditions included osteoarthritis.  An ultrasound showed gallstones and gallbladder wall thickening. A hepatobiliary iminodiacetic acid (HIDA) scan showed a cystic duct obstruction suggestive of acute cholecystitis.
He was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. The initial surgical plan was for a cholecystectomy. However, the patient declined operative treatment and wanted only antibiotic therapy. The patient reported feeling better. He had normal vital signs. He still had right upper abdominal tenderness on exam.
He was started on a liquid diet. The vital signs were normal. The WBC count normalized. The abdomen was non-tender and he required no pain medications. He was discharged.

An inpatient level of care was medically necessary in this case, in part, for the first 3 days. This patient presented the ED and was diagnosed with acute cholecystitis. The WBC count was elevated at 17.9 thousand (K). An ultrasound showed gallstones and gallbladder wall thickening. A HIDA scan showed cystic duct obstruction consistent with acute cholecystitis. A surgical consultation was performed. A non-surgical treatment plan was provided with intravenous (IV) antibiotics. The WBC count normalized and the patient was tolerating a diet. He was stable for discharge from the inpatient setting with continued outpatient follow up.

The patient had acute cholecystitis with right upper quadrant pain and tenderness. He had systemic signs of inflammation as supported by a WBC count greater than (>) 10, and cholecystectomy was not anticipated as interval cholecystectomy was planned per the surgical progress notes to be performed in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This is an adult with a past medical history of hypertension and atrial fibrillation who presented to the hospital complaining of chest pain and palpitations for three days duration. Upon arrival vital signs were blood pressure (BP) 112/65 and Pulse 150. Physical examination revealed an irregular heart rhythm.  12 lead electrocardiogram (EKG) revealed atrial fibrillation with rapid ventricular rate up to 151.  Serum blood testing was significant for elevated ethanol level. Serum troponin and B type natriuretic peptide levels were not elevated. The patient was admitted to the hospital for treatment of atrial fibrillation with rapid ventricular rates.  Attempts to control heart rate with metoprolol and diltiazem resulted in a drop in blood pressure. The patient was admitted to the hospital for treatment. Echocardiogram revealed left ventricular ejection fraction (LVEF) of 70 percent (%).  He was loaded with digoxin and ultimately, he reverted to normal sinus rhythm. 

Admission for monitoring and treatment was medically necessary.  Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. (Reference 1) An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 2) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital.  The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. 

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain.
Treatment: Decompression Surgery and Arthrodesis.
The insurer denied: Decompression Surgery and Arthrodesis.
The denial is overturned.

The patient is an adult female. The physician planned a two-stage procedure - first, decompression with anterior fusion of lumbar vertebrae five to sacral vertebrae one (L5-S1), followed by posterior fusion of lumbar vertebrae five to sacral vertebrae one (L5-S1). The patient attempted multiple sessions of chiropractic care. Imaging shows grade 1 spondylolisthesis with pars defects.

The proposed treatment is medically necessary based upon standard of care.

This patient has significant nerve root compression and pars fracture with clinical findings that would support undergoing surgery without undergoing additional nonsurgical management. The imaging does demonstrate stenosis and pars fracture which would warrant the fusion recommended. Additional nonsurgical management is not appropriate or necessary in this setting and the patient failed an adequate trial of nonsurgical management. The patient has significant pain that has not responded to multimodal treatment, and this would be considered the likely 
cause of the patient's symptoms. 
The patient was recommended for a two-stage anterior/posterior instrumented fusion. This is well accepted within the literature and spine surgery community. The patient underwent an anterior fusion to stabilize the spine and the posterior instrumented fusion is required to stabilize the spine and provide additional stabilization. It is standard of care to follow anterior fusion with posterior fusion for added stability or the spine. Therefore, the decompression and fusion are considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Body Aches and Cough.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male with a history including COPD (chronic obstructive pulmonary disease), HIV (human immunodeficiency virus), and substance abuse disorder. He presented with body aches and productive cough. He was noted to think he was withdrawing from heroin.
The patient's vital signs were remarkable for BP (blood pressure) 167/119. The patient's pertinent labs included WBC (white blood count) 14.6 and sodium 135. Chest x-ray shows cardiomegaly. 
Treatment included IV (intravenous) fluids, labetalol, IM (intramuscular) Naloxone, and nebulizer.
The patient was admitted. The next day, he was refusing labs. He complained for lethargy, nausea, diarrhea and abdominal pain. ID (infectious diseases) consultation was performed. 
He signed out AMA (against medical advice) on Day #3.
The health plan denied coverage of the admission, noting the patient could have continued work up at an observation level of care. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

This patient with a history of substance abuse was admitted for possible opiate withdrawal. The health plan denied coverage of the admission, noting the patient could have continued work up at an observation level of care. There is no evidence of hemodynamic instability. The patient's labs were remarkable for mild leukocytosis. There was no evidence of infection. Chest x-ray did not show pneumonia. He was admitted for monitoring and further work up. There is no documentation of severe withdrawal that required an inpatient care. He did not receive intervention that required an inpatient level of care and had not failed an observation level of care.
Therefore, given the above, the requested inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Thinning of bones.
Treatment:  Bone Density Testing- Dual energy x-ray absorptiometry (DEXA) Bone density study.

The insurer denied Bone Density Testing- Dual energy x-ray absorptiometry (DEXA) Bone density study.  The determination is upheld.

The patient is requesting coverage for a bone density study of the peripheral skeleton (e.g., radius, wrist, heel) to evaluate osteopenia. The patient states in an appeal request that they have been diagnosed with a multinodular thyroid, and their provider is concerned about osteopenia. A dual energy x-ray absorptiometry (DEXA) bone density study was performed of the spine and hip and was normal. At issue is the requested health service/treatment of Dual energy x-ray absorptiometry (DEXA) Bone density study.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the information provided it cannot be certified that the dual energy X-ray absorptiometry (DEXA) bone density study of the peripheral bones was medically necessary. There is no evidence that the patient has parathyroid disease or that parathyroid surgery is being considered. In addition, there is no evidence that there was a contraindication for the patient to undergo a dual energy X-ray absorptiometry (DEXA) of the spine and hip. Therefore, based on the standard of care, as well as the peer reviewed literature, the requested service/treatment was not medically necessary.

The requested health service/treatment of dual energy x-ray absorptiometry (DEXA) bone density study of the peripheral bones was not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastric Reflux
Treatment: Outpatient Linx Procedure
The insurer denied the outpatient Linx procedure.
The denial is overturned.

The patient is an adult female with chronic long-standing GERD (gastroesophageal reflux disorder). She has been compliant of twice daily PPI (proton pump inhibitor) therapy and continues to have symptoms of GERD. She underwent endoscopy, which did not show any large hiatal hernias. UGI (upper gastrointestinal study) showed small hiatal hernia, DeMeester score is greater than 15, and she has normal motility. The request is for MSA (magnetic sphincter augmentation) for management of GERD.

The health plan should cover the requested Linx procedure.

The use of MSA in the role of GERD has been shown to be effective in patients with no hiatal hernias and with small and large hiatal hernias. This patient has evidence with a high DeMeester score of acid reflux and normal manometry. This patient has failed outpatient medical therapy and meets criteria for GERD surgical management. There is a breadth of scientific evidence demonstrating the effectiveness, safety, and reduction of symptoms with MSA for GERD. Benefits of this treatment versus standard laparoscopic treatments include preservation of normal anatomic structures and less gas bloat compared to traditional surgical techniques. This patient does not have any contra-indications to this procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Treatment: Rinvoq
The insurer denied Rinvoq.
The determination is upheld.

This is a male patient with a history of Crohn's disease. He has tried and failed many therapies, including infliximab and corticosteroids. The requested service is Rinvoq. At issue is whether the Rinvoq is medically necessary for this patient.

The medical necessity of Rinvoq cannot be established. Rinvoq is a selective janus kinase (JAK) inhibitor that is being used in several immune-mediated inflammatory disease. Rinvoq is Food and Drug Administration (FDA) approved for the treatment of ulcerative colitis in adults. The safety and efficacy of Rinvoq are well established in adult ulcerative colitis patients. According to Sandborn, William J., et al: "8 weeks of treatment with upadacitinib was more effective than placebo for inducing remission in patients with moderately to severely active UC."
However, there is no evidence supporting the use of Rinvoq in treating pediatric Crohn's disease. The safety and efficacy of this treatment are not well supported by the current literature. There are more suitable therapies that have not been tried in this case. Therefore, the requested treatment is not consistent with the generally accepted practices and is unproven and not medically necessary. Medical necessity is not established due to lack of supportive literature of using Rinvoq in pediatric Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Type I Diabetes.
Treatment:  Acute Rehabilitation Facility Admission.

The insurer denied coverage for Acute Rehabilitation Facility Admission.  The denial is overturned. 

This adolescent with Type 1 diabetes for several years was referred to the hospital for diabetes education based on a history of recurrent admissions for diabetic ketoacidosis (DKA) associated with depression and suicidal ideation, eating disorder, and psychosocial stressors including parental separation. Her insurer has denied admission to an acute rehabilitation facility based on stating that the patient does not meet acute rehabilitation hospital criteria for admission as the clinical notes do not demonstrate a need for physical, occupational, and/or speech/language/feeding therapy.

Recurrent diabetes ketoacidosis admissions are associated with increased morbidity and mortality in pediatric patients and has been clinically associated with depression as seen in this patient. Clearly an intervention is needed to minimize this risk with comprehensive team-based approaches recommended. This is what has been recommended by the primary endocrinologist through the transfer to a hospital with a written detailed plan of care outlined. The program to which the patient has been referred improves family decision-making regarding diabetes, lifestyle choices and improvements in hemoglobin A1c (glycated hemoglobin). There are studies showing that such programs improve patient compliance with diabetes control. 

The denial also fails to address the needs of this patient and ignores the New York State (NYS) regulation 405.18 Rehabilitation Services that state: "Such services shall include but are not limited to audiology, occupational therapy, physical therapy, and speech language pathology".  

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 Acute Rehabilitation Facility admission is substantiated.