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

Diagnosis: Genetic Disorder. 

Treatment: Genetic Testing. 

The insurer denied coverage for genetic testing. 

The denial is overturned. 

This is a female patient with a history of irritable bowel syndrome, chronic headaches, anxiety, gastroesophageal reflux disease, and a family history of medullary thyroid cancer (MEN 2A syndrome). The patient had MEN2: RET gene sequencing testing because her father has medullary thyroid cancer (MEN 2A syndrome) due to a mutation in the RET gene. 

According to Krampitz and Norton (2014), "The rapid technical advances in molecular biology and accelerating improvements in genomic and proteomic diagnostics have led to increasingly personalized strategies for cancer therapy. Such an approach integrates the genomic, proteomic, and molecular information unique to the individual to provide an accurate genetic diagnosis, molecular risk assessment, informed family counseling, therapeutic profiling, and early preventative management that best fits the particular needs of each patient. The discovery of mutations in the RET proto-oncogene resulting in variable onset and severity of multiple endocrine neoplasia type 2 (MEN2) was the first step in developing direct genetic testing for at-risk individuals. Patients with germline RET mutations may undergo risk assessment and appropriate intervention based on specific mutations. Moreover, family members of affected individuals receive counseling based on understanding of the genetic transmission of the disease. Increasingly, clinicians are able to make therapeutic choices guided by an informative biomarker code. Improvements in detection and management of patients with MEN2 resulting from understanding of the RET proto-oncogene are evidence of the benefits of personalized cancer medicine."  

In this case, the patient's father has medullary thyroid cancer associated with his MEN 2A syndrome.  According to Chen et al (2010), "Medullary thyroid cancer consists of a spectrum of diseases that ranges from extremely indolent tumors that are stable for many years to aggressive types associated with a high mortality rate. Genetic testing for RET mutations has allowed identification of familial cases and prophylactic thyroidectomy for cure. The only curative treatment is complete surgical resection." 

Based on a review of the medical record and literature, screening for RET mutations is indicated in patients with known medullary thyroid carcinoma or a family history of medullary thyroid carcinoma in a first-degree relative. In this case, the patient's father has MEN2A due to a RET mutation. Thus, the requested test is consistent with generally accepted standards of medical practice and is therefore, medically necessary.

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

Based on the above, the medical necessity for the laboratory genetic testing for an inheritable disease is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay. 
Treatment: Root canal, post, core and crown for tooth #5 and crown for tooth #6.
The insurer denied the Root canal, post, core and crown for tooth #5 and crown for tooth #6. 

The denial is overturned. 

This is a female requesting benefits for a root canal procedure, including a post/core and crown for tooth #5 and a crown for tooth #6. 

Yes, the proposed root canal procedure, including a post/core and crown for tooth #5 and a crown for tooth #6, is medically necessary. 

Tooth #5 has a very large composite filling in it with recurrent (new) decay under it into the nerve. Tooth #5 will necessitate removing the infected nerve with a root canal procedure. The tooth will be very fragile and prone to fracturing after this, so a crown with a post and core will be needed to restore it and prevent it from breaking. 

Tooth #6 has already had a root canal procedure performed on it. Tooth #6 has a very large composite filling that is breaking, and a crown is needed to keep the tooth from fracturing further.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain/bowel obstruction. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a woman. Her medical history included endometriosis and ventral hernia. Her surgical history included hysterectomy. She presented to an emergency department with a two-day history of nausea and vomiting, and a three-month history of 50-pound weight loss. 

On computed tomography, the patient was diagnosed with bowel obstruction in the setting of obstructive and metastatic colon cancer. The patient was admitted at an acute inpatient level of care. She was made nil-per-os [NPO], and provided with intravenous fluids and analgesics; a naso-gastric tube was placed. 

The patient underwent colonic-stent placement. The procedure and the recovery were uneventful. 

After full resolution of bowel obstruction and full resumption of bowel function, the patient was discharged in good and stable condition with outpatient surgical follow-up. 

No, the Inpatient admission was not medically necessary. 

In general, in accordance with national/professional guidelines, patients with bowel obstruction can be admitted at an observational level of care [Maung et al.]. Indeed, most bowel obstructions resolve within three to five days with non-operative management. During this timeframe, the patient in question could have also undergone colonic stent placement [Angenete et al.; Young et al.]. 

There was no need to admit the patient at an acute inpatient level of care. She could have been safely and effectively evaluated and treated at an observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: S/p Surgery (percutaneous transluminal coronary angioplasty).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with a past medical history significant for hypertension (HTN), dyslipidemia, coronary artery disease (CAD), status post (s/p) prior percutaneous coronary intervention (PCI), known chronic total occlusion (CTO) of the distal right coronary artery (RCA), and s/p prior unsuccessful PCI of the RCA lesion. He has persistent anginal symptoms and an abnormal stress test. The patient presented for PCI of the RCA CTO. 

The patient was hemodynamically stable. Cardiac catheterization was performed; successful PCI of the distal RCA, right posterior descending artery (RPDA), and right posterolateral (RPL) branches were performed with drug-eluting stents. The patient was treated with dual antiplatelet therapy and was admitted for monitoring overnight, given the high-risk nature of the PCI. The next morning, the patient was hypotensive, and his beta-blocker was held. Intravenous (IV) fluid bolus was given. His troponin was elevated at 0.25, consistent with a peri-procedural myocardial infarction (MI). After the improvement in his blood pressure, the patient was discharged home with a plan for outpatient follow-up.

Yes, the proposed inpatient admission was medically necessary.

The patient presented for management of recurrent angina and was noted to have the obstructive disease of the distal RCA (a chronic total occlusion [CTO]) on cardiac catheterization. A coronary intervention with stent placement was performed on a bifurcation lesion on the CTO of the RCA/RPDA/RPL, which is considered a complex PCI. Post-procedure, the patient's course was complicated by an elevated troponin level, consistent with a peri-procedural MI, as well as episodes of hypotension requiring adjustment of medical therapy and fluid boluses. Patients such as this one were excluded from the studies of outpatient PCI. It would be consistent with the current standard of care that this patient, after this complex PCI with elevated troponin, is managed in an inpatient setting, and therefore, the requested inpatient admission was medically necessary for this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhabdomyolysis and schizophrenia 
Treatment: Inpatient hospital admission 

The insurer is denied coverage for inpatient hospital admission. The denial is upheld. 

This is a male patient who was transferred from the inpatient psychiatric unit to the telemetry unit for syncope. He was admitted for Rhabdomyolysis and schizophrenia with mania and psychotic features. Labs results showed lithium levels were high (> 6 me q/L). The patient only received 3 doses of 300 mg of lithium, the lab later identified the lab error, apparently the lithium was a false positive. The repeat Li level was less than 0.2 me q/L. Creatine phosphokinase (CPK) was 2339 down to 1580. Intravenous (IV) fluids were given and increased fluid intake was encouraged. The patient's clinical condition improved significantly with medical management and nursing care. The patient was transferred back to the Psychiatric unit. 

The lithium level of > 6 me q/L that quickly went to less than 0.2 me q/L could be only due to lab error. The high initial lithium was not due to dehydration. The HR was 70s and BP was consistently normal. There was no prolonged capillary refill or poor perfusion. Moreover, there is no specific lithium toxicity such as EKG abnormality nor Nausea/vomiting/elevated creatinine/leukocytosis. The mild elevation of CPK of 2300 was treated with NS and IV fluids. The patient was quickly transferred to Psychiatric floor. The patient remained hemodynamically stable throughout the hospitalization. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, Hypertension
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld.
This is a female patient who presented to the Emergency Department (ED) with complaints of pain.  She has a history of lupus pericarditis and end-stage renal disease. The patient reported that she woke up with a swollen face. The patient was on antibiotics for PNS finishing the course approximately 1 week prior. The patient stated that her chest pain was worse with taking a deep breath. The patient's physical examination revealed a heart rate of 99 bpm with a blood pressure of 165/130. The patient's oxygen saturation was 100%. The documentation indicated that the patient's airway was patent and she did have swollen eyelids. It was recommended that the patient undergo laboratory and diagnostic studies. The patient's laboratory results revealed a BUN of 50 with creatinine of 8.1. The patient's estimated GFR was 6.19 and troponin was 0.06. The patient's hemoglobin was 8.2 and hematocrit was 26.9. The patient's computed tomography (CT) scan of the head revealed no acute intracranial hemorrhage or significant change. The patient's chest x-ray did reveal mild pulmonary congestion with stable mild left basilar atelectasis. Nephrology was consulted. It was suggested that the patient's chest pain was likely secondary to uncontrolled hypertension; her troponin level was elevated in the setting of ESRD. The patient continued to receive multiple medications and received hemodialysis while hospitalized. The patient had 1290 ml of fluid removed via hemodialysis. The patient was clear for discharge on the following day.

Based on the review of the medical record and the literature, inpatient admission was not medically necessary for this patient. The patient presented with hypertensive urgency and required care beyond the Emergency Room. The patient required pain control, titration of her blood pressure medications, and hemodialysis prior to discharge home. However, there is no clinical evidence that the patient could not have been managed in the observation setting. Thus, inpatient admission was not medically necessary.

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Bronchitis
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is upheld.
This is a male patient who has a history of polysubstance abuse - Heroin, Cocaine, Alcohol and tobacco. The patient had been on Suboxone. He presented to the emergency department (ED) with complaints of difficulty breathing, fevers, and mild chest pain. The patient reported some productive cough with whitish/green sputum. His presenting vital signs were: temperature 98.2, Heart Rate 58, Respiratory Rate 20, Blood Pressure 128/83, and oxygen saturation (O2 sats) 99%.  The patient was awake and alert.  Laboratory work up was performed that revealed white blood count (WBC) was 7.4K, Hb 14.5, Electrolytes and BUN/ Cr were within normal limits. CO2 31, pH on venous blood gas (VBG) was 7.39 Influenza screen was negative. Troponin was negative. BNP was normal. Electrocardiogram (EKG) did not show any acute ischemic changes. Urine toxicology was positive for Cannabinoids, Cocaine and opiates. Chest x-ray did no reveal any acute infiltrates. The patient's treatment included intravenous (IV) antibiotics, steroids, bronchodilators, and Suboxone. The patient improved with treatment.


The patient was admitted for Acute Bronchitis/Asthma as per the history and physical. Vital signs were: Temperature 97.9, Heart Rate 69, Respiratory Rate 18, Blood Pressure 127/89, and oxygen saturation (O2 sats) 95% on room air. The patient was in no acute distress. The lung exam revealed mild rhonchi. The patient was continued on oral antibiotics, bronchodilators, and Steroids.

This patient did not need acute hospitalization. He was afebrile and hemodynamically stable, and improved with treatment in ED. The patient had a normal WBC, was not hypoxic on room air, and the chest x-ray did not reveal any pneumonia. CURB 65 score was Zero. The patient was tolerating oral intake. He could have been placed in Observation status while diagnostic testing and treatment were initiated. The admission was for Acute Bronchitis. The patient remained afebrile and HD stable after admission. Myocardial infarction (MI) was ruled out. The patient was stable for discharge on oral antibiotics and steroid taper along with bronchodilators

The patient did not exhibit signs of withdrawal and was tolerating Suboxone. The patient could have been followed up closely in the outpatient setting post discharge.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Care Assistance of 5 days per week, 8 hours per day for a total of 40 hours per week
The insurer denied coverage for Consumer Directed Personal Care Assistance of 5 days per week, 8 hours per day for a total of 40 hours per week. 
The denial is reversed. 

This patient is a female with diagnoses that include dementia, hyperlipidemia, anemia, hypertension, and falls. As per the UAS for the final quarter of 2019 and physician's records, the patient has dementia. The UAS also identified some physical symptoms and limitations. Physical and cognitive impairment have contributed to the patient's functional decline. The patient applied for consumer directed personal assistance services (CDPAS) and was approved for 30 hours per week. The patient requested 40 hours per week which was denied by the insurer. An external appeal was requested.

As per the UAS, the patient needs a high level of assistance for all IADLs; i.e. maximal or extensive assistance, or total dependence. The patient lives in an apartment in a building without a working elevator. There are 29 steps to enter the apartment and the patient needs extensive (weight-bearing) assistance for stairs.  As per the UAS, the patient needs limited assistance for most ADLs; except supervision for eating, and setup help (independent) for walking and bed mobility.
The UAS description of the patient's mental status indicates patient has substantial cognitive impairment. Decision making is consistently poor or unsafe, with cues and supervision required at all times. She has short term and procedural memory problems. Behavioral issues include verbal abuse, resisting care, wandering. Mini Mental Status Exam (MMSE) was 12/29 (lower end of range for moderate cognitive impairment). It was noted patient's primary language is Creole; son was present for assessment. There were no notes indicating language was an obstacle for most of MMSE; except writing a sentence was noted as N/A. 

Dementia is associated with functional decline. For a person with dementia, decreasing ability to perform daily activities (IADLs and ADLs) is an expected consequence as the disease progresses. The ability to perform IADLs often declines before ADLs, as IADLs typically require more complex cognitive skills. This appears to be reflected in this patient's functional assessment, as her IADL assessment indicates a higher level of dependence on caregiver assistance compared to ADLs. However, the patient needs limited assistance or supervision for most ADLs. It is likely that the patient's cognitive impairment has a substantial adverse effect on the patient's ability to perform daily activities.

Consumer Directed Personal Care Assistance Services 5 days per week, 8 hours per day, total of 40 hours per week is medically necessary. The health plan did not act reasonably in the best interest of the patient.

Based on the above, the medical necessity for the requested Consumer Directed Personal Care Assistance of 5 days per week, 8 hours per day for a total of 40 hours per week is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces and periodic visits
The insurer denied the braces and periodic visits.
The denial is overturned.

The Braces and periodic visits are medically necessary.

The patient has a deep, impinging overbite which is causing trauma to the palatal gum tissues. This is an "automatic qualifier" on the handicapping index scale. The patient needs orthodontic treatment to correct this problem. This case has medical necessity for the orthodontic treatment and the follow up visits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity
Treatment:Single-Anastomosis Duodenal Switch for Weight Loss (Conversion of Sleeve Gastrectomy to Biliopancreatic Diversion with Duodenal Switch) (43845)
The insurer denied the Single-Anastomosis Duodenal Switch for Weight Loss (Conversion of Sleeve Gastrectomy to Biliopancreatic Diversion with Duodenal Switch) (43845).
The denial is overturned.

Based on the submitted clinical material, the proposed revisional operation is medically necessary at this time for this patient.

The patient is a female who underwent laparoscopic sleeve gastrectomy years ago.  This was performed as a bariatric operation as treatment for morbid obesity. The patient initially realized 100 pounds (lbs) weight loss following sleeve gastrectomy.  She has since gained weight.  Her weight nadir post sleeve gastrectomy was 260 lbs.  She maintained this weight loss for approximately 18 months. 

The submitted documentation does support that the proposed revisional bariatric operation is medically necessary for this patient based on current literature, current standards, and the presurgical requirements of the treating surgeon.  

This patient underwent sleeve gastrectomy. She lost 100 lbs following this operation.  However, she has since gained weight and has a BMI in excess of 50 kg/m2.  The submitted records do document refractory morbid obesity despite nutritional follow up.  Additionally, the submitted records now include an anatomic evaluation of the sleeve with EGD. 
Inadequate weight loss (at least 50% of excess weight) greater than (>) two years following the primary bariatric surgery with documentation of patient compliance with a prescribed nutrition and exercise program or if there are complications of the initial bariatric operation that require operative revision is considered as medically necessary criteria for revisional bariatric surgery.

In this case there is documented nutritional / exercise follow up with refractory morbid obesity. There is also documentation of her existing anatomic changes post gastric sleeve.  
Biliopancreatic diversion with duodenal switch is an effective weight loss operation with sustained weight loss that is in excess of that seen with sleeve gastrectomy.  This patient is morbidly obese and has completed the appropriate presurgical evaluation to support the medical necessity of the proposed operation. Therefore, the proposed revisional operation is medically necessary at this time for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Issue under review: Inpatient admission

Determination:
The denial was overturned.

The patient is an adult female. She presented to the ER with a history of asthma with worsening SOB (shortness of breath) and wheezing. 

Despite receiving multiple nebs and IV steroids, the patient continued to have dyspnea, wheezing and was admitted to acute in-hospital level of care. The patient continued to receive IV steroids and frequent nebulization treatment during her hospitalization and continued to have dyspnea, wheezing and using accessory muscles. The patient's asthma exacerbation was resistant to quick improvement.

The patient had new onset worsening dyspnea and wheezing. Despite emergency room care, the patient's asthma exacerbation was resistant to treatment and required prolonged IV steroids and nebulization treatment for improvement. 

Thus, the acute in hospitalization for asthma exacerbation was medically necessary.