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

Diagnosis: Orthopedic/Musculoskeletal/Osteoarthritis
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistant hours due to the lack of medical necessity. 
The health plan's determination is overturned.

The patient is a female with past medical history of dementia, osteoarthritis, hypertension, legal blindness, asthma, gastroesophageal reflux disease (GERD), glaucoma, atrial fibrillation, vitamin B12 deficiency, vitamin D deficiency, hearing loss, urinary and bowel incontinence who had shared personal care assistant (PCA) services with her husband 24 hours/day, split-shift, 7 days/week, but he expired. The patient previously had a telephonic assessment tool, assessing the patient at total assistance with the task of managing finances while maximum assistance with tasks of meal preparation, ordinary housework, managing medications, phone use, stairs, shopping, transportation, equipment management, and bathing. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility while supervision with task of eating. The patient had another telephonic assessment tool, assessing the patient at total assistance with tasks of ordinary housework, managing finances, and shopping while maximum assistance with tasks of meal preparation, managing medication, phone use, stairs, transportation, bathing, dressing lower body, and toilet use. The patient was assessed at extensive assistance with tasks of personal hygiene, walking, locomotion, and transfer toilet while limited assistance with tasks of bed mobility and eating. 

The health plan's determination of medical necessity is overturned, in whole.

Yes, the patient has documented progressive and worsening medical conditions of dementia and osteoarthritis. The patient requires at least limited assistance with all activities of daily living (ADLs) and instrumental activities of dialing living (IADLs). The nurse assessment underestimated the patient's care needs. The patient had unscheduled and unpredictable care needs over a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's family documented that the patient lived alone and not with her son as the plan noted. The increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, live-in 7days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary
Home Health Care

Diagnosis: Urinary tract infection
Treatment: Consumer Directed Personal Assistant Services (CDPAS) 7 Days x 24 Hours (Continuous Services)
The insurer denied Consumer Directed Personal Assistant Services (CDPAS) 7 Days x 24 Hours (Continuous Services). The health plan's determination is upheld. 

The patient is a female with a past medical history significant for chronic urinary tract infections, compression fracture, anxiety, dementia, coronary artery disease, chronic obstructive pulmonary disease (COPD), hypertension and recent ST-Elevation Myocardial Infarction (STEMI).

Consumer Directed Personal Assistant Services (CDPAS) 7 Days x 24 Hours (Continuous Services) is not medically necessary for this patient.

Additional services are not medically necessary and can be addressed through the current services being provided.

The patient was recently in the hospital, secondary to these conditions. She has had a decline subsequently. Per the Uniform Assessment System (UAS) State of New York, the patient requires total or maximal assistance for most activities of daily living. There is no documented medical condition that requires the patient to need frequent assistance throughout the night, specifically with toileting needs that a live-in personal care aide cannot provide.

From documentation provided, there does not appear to be any needs that cannot be met through the provided services of a 24-hour live-in aide. Specifically, there are no nocturnal needs that would preclude an aide from getting adequate sleep (defined as at least 6 hours of uninterrupted sleep). The patient has no medical need for frequent turning and positioning, such as for skin wounds or decubitus ulcers. She does have noted incontinence; however, she does have a catheter in place for the urinary incontinence. There is no need for the patient to get up or be monitored otherwise throughout the night. There are no provided nocturnal logs to substantiate services that are required through the night. There is no provided information stating that the aide does not have adequate space to stay in the residence and/or have enough personal time for sleep.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder-Urinary Tract Infection/UTI
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

This patient has a history of nephrolithiasis, who had a percutaneous nephrostomy(PCN) tube placed for an obstructing renal stone on prior to admission with concomitant issues including urosepsis, and septic shock.
She was admitted for intravenous (IV) antibiotics prior to definitive stone surgery/Percutaneous Nephrolithotomy (PCNL) following a consultation with Infectious Disease. Surgery was then delayed by four additional days during which time IV antibiotics were given. Following discharge she was continued on oral antibiotics. 

The inpatient hospital stay was not medically necessary for this patient.
The patient had a preoperative urine culture. She was not toxic upon admission. She did not have acute issues warranting inpatient hospital level of care. The preoperative antibiotics may have been safely administered at a lower level of care.
Chew and associates reported on prophylactic antibiotic use, noting no advantage to their use compared to standard prophylaxis.(4) 
Lower level of care therapy for a complicated urinary tract infection (UTI) has been shown to be effective. Trad, et al noted that use of the appropriate antibiotic in this case, ertapenem, may be safely and effectively administered in a lower level of care setting.(5)
The patient had no postoperative issues mandating acute level of care including hemodynamic instability, electrolyte abnormality, issues with oral intake or elimination, or fever. Milliman Care Guidelines (MCG) establish parameters for admission; these were not met per chart documentation.[2] Therefore, acute care was not indicated.
Following the procedure, the patient may have been safely monitored at a lower level of care, with inpatient admission opted if the need arose.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of Right Knee

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is upheld

The patient is a female with a medical history of primary osteoarthritis of right knee, gastroesophageal reflux disease, thyroid disease, depression, exercise intolerance, chronic knee pain and prior left knee replacement. She started experiencing right knee pain which was evaluated.  Surgery was recommended. The patient presented for right knee replacement. She was admitted and underwent surgery with no complications noted. The patient received physical therapy (PT) and occupational therapy (OT). Her pain was controlled and she remained stable. The patient's Foley catheter was removed and she was discharged.

The records show the patient underwent a non-complicated total knee replacement. The surgical time was limited. There was not extensive blood loss. Her vital signs were stable with no evidence of fever. Her wound was without problem. There was no evidence of bleeding. She was able to tolerate oral pain medications and participate in rehabilitation. She did not require treatment for an underlying medical condition. No additional procedures or tests were required. These findings do not substantiate the necessity of an inpatient admission. 

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

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

Diagnosis: Urinary tract infection and severe sepsis. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a male patient with neurogenic bladder who was admitted to the hospital for urinary tract infection and malfunctioning nephrostomy tube and was started on intravenous fluid and antibiotics. The patient's creatinine level on admission was 5.1 (baseline 2.8). He was also evaluated by Interventional Radiology (IR) and underwent nephrostomy tube flushing and suprapubic catheter placement. 

The patient was admitted with severe sepsis and was hemodynamically unstable (noted with hypotension, persistent tachycardia and lactic acidosis) his condition required broad spectrum antibiotics therapy and intravenous fluid resuscitation and he underwent IR procedure including nephrostomy tube flushing and suprapubic catheter placement. 
He had a complex hospital stay and the inpatient level of care was appropriate.

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: appendicitis

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is overturned. 

This female patient with no significant past medical history.  The patient presented to the Emergency Room (ER) with complaints of 10 out of 10, abdominal pain. The patient's white blood cell (WBC) count was elevated.  The patient's computed tomography (CT) scan of the abdomen revealed acute appendicitis.  The patient was given 975 milligrams (mg) of oral (PO) acetaminophen and was admitted with appendicitis.  The patient was initially kept on nothing by mouth (NPO).  The patient was given 2 grams (g) of intravenous (IV) cefoxitin every 8 hours (Q8H) and IV morphine for pain.  The patient underwent a laparoscopic appendectomy under general anesthesia.  After surgery, the patient was given 4.5 mg of IV Zosyn Q8H and IV morphine. Strict intake and output (I&O) was monitored and sequential compression devices (SCD) were applied for deep vein thrombosis (DVT) prophylaxis.  The patient's pain was well controlled and the patient was tolerating his diet well.  The patient was transitioned to oral Augmentin.  The patient was discharged with instructions to continue on oral antibiotics on an outpatient basis and follow-up with general surgery as outpatient.

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient who presented with perforated appendix. As per literature review, admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities [e.g., chronic obstructive pulmonary disease (COPD), chronic heart failure], or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care.1-3 Patients with a perforated appendix are noted to have a longer inpatient stay. 4 

Peer-reviewed literature indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis.1-3 However; this does not apply to this patient's case who had a perforated and gangrenous appendix. This patient had a complicated case of appendicitis that required acute inpatient 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: Overturned

Diagnosis: Sarcoid-associated small fiber neuropathy
Treatment: Seven visits (drug: immunoglobulin) (J1561)
The insurer denied the Seven visits (drug: immunoglobulin) (J1561).
The denial is overturned. 

The patient is a male with systemic sarcoidosis with small fiber neuropathy.  He is prescribed intravenous immunoglobulin (IVIG) treatment. The patient has psoriasis and the biologic treatments are thought to cause sarcoidosis in this patient. The patient has neuropathic pain that is treatment resistant. The small fiber neuropathy is the likely cause of the neuropathic pain.

Yes, the proposed treatment, Seven visits (drug: immunoglobulin) (J1561) was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

Intravenous immunoglobulin therapy is Food and Drug Administration (FDA) approved for the immune-mediated peripheral nerve disorders, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. 

This patient has immune related small fiber neuropathy and has tried and failed all standard of care treatments. Intravenous immunoglobulin treatment is safe and is likely to be effective in this patient due to the fact that patient has immune related diseases (sarcoidosis, psoriasis, autoimmune hepatitis) with neuropathic pain and biopsy proven small fiber neuropathy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female.  At the time of admission to the hospital, the patient had a past medical history significant for hypertension (HTN), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dyslipidemia and polysubstance abuse.  The patient presented to the emergency room with complaints of chest pain. The patient had elevated cardiac troponins, and was admitted to telemetry for suspected acute coronary syndrome. 

The patient underwent a nuclear stress test, which revealed global left ventricular (LV) dysfunction, as well as echocardiogram, which revealed systolic congestive heart failure (CHF). A cardiac catheterization was done, which revealed no obstructive coronary artery disease (CAD), however was consistent with severe non-ischemic cardiomyopathy. The patient was started on medical therapy for non-ischemic cardiomyopathy and was discharged home with a plan for outpatient follow-up.

Yes, the proposed inpatient hospital admission was medically necessary.

The patient presented with new onset chest pain, and findings suggestive of acute coronary syndrome, including elevated cardiomarkers, consistent with myocardial end-organ damage. The electrocardiogram (ECG) was abnormal, with findings suggestive of ischemia. The echocardiogram and the nuclear stress test were abnormal as well and the patient was referred for inpatient coronary angiogram. Given this presentation, suspicion for an acute coronary syndrome, elevated troponin, as well as risk factors for coronary artery disease, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Sided Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. At the time of admission to the hospital, she had a past medical history significant for hypertension (HTN), asthma, back pain status post trauma and back surgery.  The patient presented for evaluation of chest pain, which was non-exertional, left-sided, with radiation to the left face. The patient was hemodynamically stable. The electrocardiogram (ECG) revealed no acute ischemic changes. The lab data was significant for elevated D-dimers and a computed tomography angiogram (CTA) of the chest was obtained, revealing no evidence of pulmonary embolism. There was findings of emphysematous changes, dependent atelectasis and possible mild pulmonary edema. The brain natriuretic peptide (BNP) was low. Troponin was negative on three sets. The patient was admitted to telemetry to rule out acute coronary syndrome (ACS). Her condition improved and she signed out against medical advice (AMA).

No, the inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Pulmonary embolism was ruled out in the emergency department by computed tomography angiogram. 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: Overturned

Diagnosis: Low Back Pain

Treatment: Transforaminal Epidural Steroid Injections

The insurer is denied coverage for transforaminal epidural steroid injections.

The denial is overturned.

This female patient has a history of chronic low back pain, and neck pain who is seen by her Pain Medicine Specialist for pain management. As per the office visit notes, the patient's neck pain radiate into her hands bilaterally, with numbness and tingling. Her low back pain goes into her feet with numbness and tingling, affecting ambulation and her activities of daily living.  Physical therapy and Medrol were discussed, as well as a lumbar epidural.  In an addendum, her physician notes that the patient completed 6 weeks of home instructed physical therapy and exercise for 150 minutes per week. It was also noted that the patient has a history of drug abuse in the past, on Vivitrol injection. She has never had epidurals in the past; and the patient is not comfortable taking medication due to her history.

Clinical Practice guidelines (1,2) support performing epidural steroid injection after the failure of conservative therapy. The patient has failed a home exercise program and a trial of Nonsteroidal Anti-inflammatory Drugs (NSAID).

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 transforaminal epidural steroid injections is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented with a 10-day history of right upper quadrant pain and yellowish vaginal discharge.

The patient's examination showed mild cervical motion tenderness. CT (computed tomography) scan showed a 3.6 cm (centimeter) cystic lesion presumably emanating from the right ovary. In addition, there was a possible left hydrosalpinx versus fluid-filled bowel.

No, the Inpatient admission was not medically necessary.

The presumptive clinical diagnosis of PID (pelvic inflammatory disease) is made in sexually active young women, especially women at high risk for sexually transmitted infections (STIs), who present with pelvic or lower abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam.

The sensitivity of this clinical diagnosis is only 65 to 90 percent, but because of the potential for serious reproductive sequelae if PID (pelvic inflammatory disease) treatment is delayed or not given, this presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID (pelvic inflammatory disease). Even patients with minimal or subtle findings should be treated since the potential consequences of withholding therapy are great.

So even though this patient did not have the typical PID (pelvic inflammatory disease) presentation (mild cervical motion tenderness, no fever), treating her for possible PID (pelvic inflammatory disease)  was warranted.

However, there has been a persistent trend toward outpatient treatment of PID (pelvic inflammatory disease), with only 15 percent of women now being hospitalized. Clinical trial data support such an approach in patients with mild or moderate PID (pelvic inflammatory disease).

Recommended indications for hospitalization and parenteral antibiotics include the following:

1. Pregnancy
2. Lack of response or tolerance to oral medications
3. Non-adherence to therapy
4. Inability to take oral medications due to nausea and vomiting
5. Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
6. Complicated PID (pelvic inflammatory disease) with pelvic abscess (including tuboovarian abscess)
7. Possible need for surgical intervention or diagnostic exploration for alternative etiology (eg, appendicitis)

This patient did not evidence any of the above indications. She was afebrile. Her pain was controlled with oral analgesics. She did not have nausea or vomiting, and she was able to tolerate oral intake.

Therefore, based on the above, the inpatient admission was not medically necessary.

The patient could have been treated at a lower level of care. The health plan acted reasonably by denying the hospital admission for this patient as that admission was not medically necessary.

The patient was admitted with the diagnosis of PID (pelvic inflammatory disease) and started on IV (intravenous) antibiotics.

The patient was discharged home after her pain resolved.