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


Diagnosis: hysterectomy/anemia.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a female with a past medical history remarkable anemia, uterine fibroids, who was admitted for anemia during pre-operative workup for hysterectomy. Review of system was negative for additional clinical symptoms.
The patient was afebrile (Temperature of 98.9). Her blood pressure was 139/85, pulse rate of 97, respiratory rate of 17, and oxygen saturation of 100% on room air. Physical examination was unremarkable for positive clinical findings. The patient was admitted for severe anemia. 

The inpatient hospital admission was medically necessary.
The patient was admitted for severe anemia related to menorrhagia in the clinical setting of fibroids. The patient had evidence of severe anemia that required blood transfusions and evidence of ongoing blood loss despite trial of hormonal therapy. Inpatient admission was warranted for procedural intervention and blood transfusions.
Uterine fibroids (leiomyomas or myomas), benign monoclonal tumors, are the most common benign tumors in women. Heavy or prolonged menstrual bleeding, abnormal uterine bleeding, resultant anemia is generally associated with uterine fibroids. Although curative treatment of this tumor relies on surgical therapies, medical treatments are considered the first-line treatment to preserve fertility and avoid or delay surgery. Observational data support the use of oral contraceptives to reduce menstrual bleeding in women with fibroid. When medical treatment option fails, definitive treatment with surgical intervention is warranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Social anxiety.
Treatment: Mental Health: Residential.
The insurer denied continued mental health residential stay. 
The health plan's determination is upheld. 

The patient is a male with history of severe social anxiety, unspecified depression and attention deficit disorder inattentive subtype. Prior to residential treatment, the patient failed outpatient treatment, intensive outpatient treatment and had a history of social avoidance and school refusal. He was admitted to residential care.

The continued stay at the residential care facility was not medically necessary for the patient. The records were reviewed including letters from previous providers, history of non-attendance in his high school and prior failures of lower levels of care. The patient showed significant improvement while at Ironwood. He attended and participated in treatment willingly. He was not agitated, aggressive, manic or psychotic. He did not require any standing medications for his depression or his anxiety. He was not engaging in self harm behaviors or having thoughts of harm to himself or others. He was willing to participate in groups and engage in individual, group and family therapy. He was looking forward to returning home. He did not require medical monitoring for any co-morbid conditions and tolerated his treatment without issues. He has a supportive family and access to treatment providers in his home environment and was willing to engage on the dates in question. He did show signs of anxiety and some mild avoidance but was able to be redirected. He does not meet CALOCUS (Child and Adolescent Level of Care Utilization System) guidelines for residential treatment on the dates in question for the reasons stated above and could have been safely treated in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Functional Paraplegia

Treatment: Skilled Nursing Facility (SNF)

The insurer denied coverage for SNF.

The denial is upheld.

This is the case of a female with multiple medical problems including urinary tract infection (UTI) with sepsis, functional quadriplegia, and lupus. She was admitted to the skilled nursing facility (SNF) for subacute rehabilitation. She was bedbound and had functional paraplegia. She participated in physical and occupational therapies. She was discharged to a long-term care (LTC) facility. 

The patient was initially appropriate for the SNF subacute rehabilitation level of care. (1, 2, 3) She had functional deficits that were amenable to subacute rehabilitation at the SNF level of care. Unfortunately, the treatment notes do not document evidence of significant functional improvement for the time period under review. For example, the patient continued to require moderate to maximal assistance for dressing, moderate assistance (times 2) for transfers and minimal to moderate assistance for ambulating only 20-50 feet (with wheelchair [WC] follow). In addition, there were no acute medical or complicated nursing issues that required continued care in a SNF.

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued stay at a SNF was not medically necessary.

The insurer's denial of coverage for a continued stay at a skilled nursing facility (SNF) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a male with past medical history significant for tobacco and marijuana use who presented to the emergency department (ED) with complaints of diffuse pruritic rash, that started from extremities spreading to back and chest.  Vitals on presentation included temperature of 98.5 Fahrenheit, blood pressure (BP) 155/97, heart rate (HR) 79, respiratory rate (RR) 16, and oxygen (O2) saturation 99% (percent) on room air (RA). Laboratory results included white blood cell (WBC) count trending down from 23.8 to 18.7 and creatinine 1.10.

The patient was admitted to the hospital with a possible rash developing into cellulitis. He was empirically started on intravenous (IV) antibiotics. He remained afebrile, and hemodynamically stable. While waiting in the ED, the patient left the hospital against medical advice (AMA).
 
According to documentation, patient was admitted for a possible cellulitis. Otherwise, he was afebrile, hemodynamically stable. Laboratory results were only notable for an elevated WBC.  There was no evidence of a disseminated infection, no surgical intervention was required, and patient had no significant co-morbid conditions. Based on these findings, patient met criteria for observation level of care. He did not fulfill criteria for acute care hospitalization.

The health plan acted reasonably with sound medical judgment in the best interest of the 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: Type 2 Diabetes.
Treatment: Durable Medical Equipment (continuous glucose monitor).
The insurer denied the Durable Medical Equipment (continuous glucose monitor).
The denial is overturned.

The patient is a female. She was diagnosed with T2DM (type 2 diabetes mellitus). This request is for Dexcom G6 CGM (continuous glucose monitor) sensor and receiver. As reported, she has congestive heart failure (she had surgery to install a pacemaker and defibrillator), asthma, and HTN (hypertension). She is on Humalog via Omnipod; Jardiance 25 mg (milligrams) daily; Toujeo 26 units once daily. She checks her BG (blood glucose) 6 times daily. She was on Freestyle libre.

The patient's A1C (glycated hemoglobin) was 8.7 %. Approximately a year prior it was 7.8 %.

Yes, the continuous glucose monitor is medically necessary.
Continuous glucose monitoring systems, including real-time systems, have FDA (United States Food and Drug Administration) approval [1]. They are not the subject of Phase I-III clinical trials. The peer reviewed literature supports the long-term use of CGMS (continuous glucose monitoring systems) in adult (25 year old) patients. The ADA (American Diabetes Association) position statement on standards of medical care in diabetes published [2], states, "Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C [glycated hemoglobin] in selected adults (age 25 years) with type 1 diabetes." The ADA considers this to have a level of evidence of "A," which is "Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered."

There are emergent studies showing benefit of continuous glucose monitoring over blood glucose monitoring in patients with type 2 diabetes while on basal insulin such as this patient. The studies show improvement in hemoglobin A1C (glycated hemoglobin) [3]. The patient has previously benefited from continuous glucose monitoring. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient, as the request is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease). 
Treatment: LINX Reflux Management System (LINX) (43284). 

The insurer denied the LINX Reflux Management System (LINX) (43284). 
The denial is overturned. 

The patient is a female with a several year history of reflux symptoms. She notes belching and burping as symptoms. She takes Aciphex for her symptoms, and becomes symptomatic if she misses a dose. She has under gone EGD (esophagogastroduodenoscopy), manometry, and pH (potential Hydrogen) testing, which showed no hiatal hernia, normal motility and high Demeester score. 

Yes, the health plan should cover the LINX procedure. 

The patient meets need for anti-reflux surgery. The LINX system has been shown in multiple clinical trials to be effective and safe for reflux control. 

Yes, the LINX procedure is more beneficial. 

LINX system has been shown to be beneficial in lessening gas bloat syndrome compared to laparoscopic Nissen fundoplication. The patient does not have a hiatal hernia and only complains of refractory reflux symptoms. Her motility is normal. Laparoscopic Nissen Fundiplication can alter the anatomy of the native  esophagus and stomach and is difficult to revise. In this patient, the LINX system would be the most beneficial system to control her GERD symptoms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: toe gangrene.
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a female with a past medical history significant for type 2 diabetes mellitus, hypertension, morbid obesity, and a left foot wound who presented to the hospital with complaints of left foot pain and swelling. Her symptoms started 1 week before the presentation. The patient stated that she stumbled on concrete 1 week before her coming to the hospital. Subsequently, she noticed swelling in the proximal aspect of the foot, spreading to the calf. The patient denied fever but had purulent drainage from the wound. One day before admission she was seen by a podiatrist who noted gangrene of the left foot. Reportedly, the patient was seen by podiatry service and underwent amputation of the second toe.

The inpatient hospital admission was medically necessary.
Based on nationally accepted standards of care, admission at the inpatient level of care for patients with cellulitis or soft tissue infection is generally indicated in cases when the infection is associated with uncontrolled diabetes. In this clinical case, the patient's hemoglobin A1c was 10% (percent), confirming the diagnosis of uncontrolled diabetes mellitus. The presence of uncontrolled diabetes mellitus significantly increases the chances of adverse outcomes, therefore treatment with intravenous antibiotics in the hospital setting was completely justified until the decision was made to switch the patient to oral antibiotics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell disease, posterior reversible encephalopathy syndrome (PRES), and
vascular necrosis of the right hip. 

Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

This is a male patient with a history of sickle cell disease, posterior reversible encephalopathy syndrome (PRES), and avascular necrosis of the right hip who was admitted for a persistent headache.  The pain was unresponsive to oxycodone at home. He was evaluated in clinic and sent to the emergency department (ED). 

The patient's exam was normal.  His labs showed a mildly elevated white blood count and an elevated D-dimer.  Due to his history of posterior reversible encephalopathy syndrome and also due to concern for a sinus venous thrombus, he was admitted for a brain magnetic resonance image (MRI.)  A partial exchange transfusion was performed. He was started on maintenance intravenous fluids.  A magnetic resonance image was normal.  The patient was given one dose of Tylenol. The patient's pain was improved, and he was discharged home. 

The plan denied the hospital stay stating that the care could have been provided at a lower level of care. 

Yes, the requested inpatient hospital stay was medically necessary. 

The patient has a medical history significant for posterior reversible encephalopathy syndrome (PRES) and sickle cell disease.  Due to his symptoms and laboratory abnormalities, he was at high risk for stroke, recurrence of posterior reversible encephalopathy syndrome (PRES), or a sinus venous thrombosis.  He required an acute inpatient hospital stay for close neurologic monitoring, performance of an exchange transfusion (with frequent vital sign monitoring), diagnostic evaluation, and pain control.  Based on the intensity of services provided and the acuity of the patient's condition, the requested acute inpatient hospital stay was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient as the acute inpatient hospital stay was medically necessary. 
Please see discussion above.  Based on the high risk nature of the child's condition and the necessary interventions (exchange transfusion, diagnostic evaluation, and cardiorespiratory/neurologic monitoring), the acute inpatient hospital setting was medically necessary for this stay.  The health plan did not act reasonably, with sound medical judgement, nor in the best interest of the patient by denial of the acute inpatient hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease.
Treatment: Enteral therapy (Ensure).
The insurer denied the Enteral Therapy (Ensure).
The determination is overturned.

The patient has a history of end stage renal disease (ESRD) on dialysis three times a week, mild dementia, recent cerebrovascular accident (CVA) with aphasia. The provider is prescribing Nepro 8 ounces (oz) once a day for moderate protein calorie malnutrition. The patient's current weight is 54 kilograms (kg) with usual weight documented at 66kg which represents an 18% loss of body weight. Albumin 3.0 milligrams per deciliter (mg/dl). He has no documented swallowing difficulties. The health plan has denied Enteral Therapy (Ensure) due to a lack of documentation for medical necessity.
At issue is the medical necessity of Enteral therapy (Ensure).

The requested service of enteral therapy is medically necessary. The provider is prescribing Nepro 8 oz daily for moderate protein calorie malnutrition, based on documented hypoalbuminemia and 18% weight loss over the past two months. The patient has documented moderate protein calorie malnutrition as demonstrated by his hypoalbuminemia and his 18% total body weight loss over the past two months.  It is medically necessary for him to be on nutritional supplements to combat this malnourished state. The Ensure which was denied by the health plan would provide the medically necessary protein nutrition. Therefore, the Ensure is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: peripheral arterial occlusive disease.
Treatment acute patient stay.
The insurer denied coverage for acute patient stay.	
The denial is overturned.

This case involves a patient who presented to the emergency department complaining of worsening left lower extremity pain.  He indicated his pain has been present for a month.  He stated his pain increases with walking and he was having pain with rest.  According to the appeal documentation submitted he had previously been seen by vascular surgery with an abnormal pulse volume recording.  He does have a past medical history significant for chronic obstructive disease (COPD) as well as Crohn's disease.  The physical exam revealed an absent left foot pedal pulse.  There was a nonpalpable femoral pulse.  The recommendation was made to admit the patient to have him undergo a left endarterectomy and patch angioplasty.  The following day he received cardiac clearance and underwent surgical intervention.  He was discharged with instruction to follow-up.

The patient had a one-month history of left leg claudication and known peripheral arterial occlusive disease.  The patient had outpatient non-invasive imaging with Pulse Volume Recording.  This test was abnormal and thus patient was scheduled for an outpatient angiography. However, he presented to the emergency department with left leg rest pain, which was a clinical worsening than his previous claudication.  Given the change in the patient's symptomatology, a CT (compute tomography) angiogram was ordered, and it revealed critical left common femoral occlusive disease, best treated with surgical revascularization.  

Given his multiple co-morbidities, he had cardiac clearance, and following this, on the same day, he underwent a left femoral endarterectomy with patch angioplasty.

He did well and was discharged on postoperative day 1.

This patient was managed appropriately, as rest pain is a marker for the threat of limb loss and is much more serious than claudication.  Given the risk of limb loss, the ordering of angiography and immediate surgery was indicated.  

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 acute patient stay is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Anal Dysplasia

Treatment: high resolution anoscopy (46607)

The insurer denied coverage for high resolution anoscopy (46607)

The denial is overturned

This case involves a male who has been recommended to undergo a high-resolution anoscopy.  He has been receiving treatment for human immunodeficiency virus (HIV) and that has a history of abnormal anal Pap cytopathology.  He also has a positive result for human papilloma virus (HPV) by polymerase chain reaction (PCR) anal swab.  Given the above it was recommended he undergo anoscopy to screen for precancerous cells.

However, there is promising data in high resolution anoscopy (HRA)'s favor.

National guidelines recommending anal screening for precancerous lesions have not been adopted by the United States Public Health Service. HIV Medicine Association of the Infectious Diseases Society of America makes a weak recommendation based on moderate-quality evidence for screening with anal cytology.

He has an abnormal anal cytology and performance of HRA is currently considered standard of care as the HRA allows for a more accurate sampling. 

An abnormal anal cytology screening test should be followed by HRA for a diagnostic biopsy.

HRA refers to the examination of the anal canal and perianus using a colposcope for lighting and magnification, after application of 5% (percent) acetic acid and Lugol iodine solutions to identify anal lesions. This procedure allows the clinician to visualize the lesions that represent the source of abnormal cells on cytology screening or HPV if HPV testing was used as the screening test and obtain biopsy specimens for histopathologic assessment. 

Anal histopathology is necessary to grade the severity of the disease; this cannot be accurately established with visual evaluation or cytology alone. 

The goal of the biopsy is to identify HSIL (high grade squamous intraepithelial lesion), or invasive anal cancer since these may be targeted for treatment. This test is appropriate, the best available and likely to be more beneficial than any other testing without increased adverse risk.

The carrier's denial of a high resolution anoscopy (46607) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Anal Dysplasia

Treatment: high resolution anoscopy (46607)

The insurer denied coverage for high resolution anoscopy (46607)

The denial is overturned.

This is a male with human immunodeficiency virus (HIV) and pre-cancerous cells on prior pap smears. An anoscopy showed squamous mucosa with anal intraepithelial neoplasia grade 2 (AIN2)-high grade dysplasia and cytologic features of human papilloma virus (HPV) infection. A repeat anoscopy to eliminate areas of dysplasia has been requested.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Per Hirsch, B. E, McGowan, J.P, Fine, S.M, (2022), "This guideline on screening for anal cancer and dysplasia in individuals with HIV was developed by the Medical Care Criteria Committee (MCCC) of the New York State (NYS) Department of Health (DOH) AIDS (acquired immunodeficiency syndrome) Institute (AI) Clinical Guidelines Program. Its purpose is to inform clinicians in NYS who provide primary care to individuals with HIV about human papillomavirus (HPV)-related anal disease and assist them in identifying opportunities for prevention, screening, and treatment. Accordingly, this guideline addresses the following topics: HPV transmission, prevention, and screening and the diagnosis, follow-up, and treatment of HPV-related anal disease.

The issue has approval from a regulatory body for the patient's diagnosis.

It follows the New York State Aids Institute Guidelines for screening for anal dysplasia in persons living with HIV.     

The patient a good candidate for the listed issue.

The patient meets all criteria for this procedure.     

Based on peer reviewed published literature and industry guidelines, this is the best available treatment.

The adverse risks are not increased over standard treatment/services. This test is likely to be more beneficial to the patient that any other testing.

The carrier's denial of a high resolution anoscopy (46607) should be overturned.