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

Diagnosis: Reflex Sympathetic Dystrophy/ Complex Regional Pain Syndrome
Treatment: Durable Medical Equipment (Electric Scooter)

Summary: This patient has reflex sympathetic dystrophy (RSD)/complex regional pain syndrome (CRPS) involving her right (R) leg. Symptoms began three years ago when a bone graft was taken from her right fibula to treat a jaw defect due to odontogenic myxoma. She also has hyperlipidemia, diabetes Type 2, seizures, anxiety and depression. Per an office visit with her Neurologist, the patient's symptoms began three years ago and were described as severe. Pain was in the foot, ankle, leg, hips and back. Aggravating factors include walking and getting out of a chair. Relieving factors include lying down. The patient's pain was chronic and poorly controlled. Her body mass index (BMI) was 36.21. On exam, the patient's right leg was redder and cooler. The patient presented to Balance Therapeutics for evaluation of a recent onset of low back pain secondary to RSD of the right lower extremity. She reported swimming with good relief in the water, but worsening pain on exiting the water. She was utilizing medical marijuana occasionally with significant improvement. She had an altered gait pattern and hypersensitivity of the right lower extremity. Physical therapy twice weekly for 12 weeks was recommended.  The Neurologist has ordered an electric scooter (GoGo Elite traveler scooter) for the patient.

The insurer has denied coverage for K0800 Power Operated Vehicle, group 1 standard, patient weight capacity up to and including 300 pounds as not medically necessary. The denial was upheld.

While the appeal letter from the Neurologist states that she needs a scooter, neither this letter nor the medical records explain why a scooter is medically necessary. The doctors' recommendations stated in his office notes are for medication for pain control. The physical therapist's recommendations are for physical therapy (PT) and desensitization of right leg pain. Medical organizations emphasize the importance of maximizing exercise in the treatment of RSD; a scooter to decrease limb use would be expected to minimize exercise. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alcohol Abuse
Treatment: Inpatient Hospital Admission for Detoxification Treatment

Summary: This patient was admitted to inpatient hospital treatment due to alcohol withdrawal. He had withdrawal symptoms including nausea and vomiting 5-6 times, elevated heart rate of 99 and elevated blood pressure of 165/102, agitation, tremors, tongue fasciculation, weakness, diaphoresis, and he had poor oral intake. He was drinking 2/5 of vodka per day. He reportedly had multiple past inpatient detoxification treatments. He had a medical history significant for deep vein thrombosis, dehydration, sleep apnea, back pain, and alcohol cirrhosis, and also had reports of depression and anxiety. He had a past suicide attempt. He reportedly took Librium and had intravenous Versed, normal saline, thiamine, and folate. He had deconditioning and weakness.
 
The insurer denied coverage for the inpatient hospital treatment for detoxification treatment as not medically necessary. The denial was modified.

The denial was partially approved because he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use alcohol after inpatient detoxification treatments and he needed detoxification medications to modify withdrawal. Chart notes reported that he still had alcohol withdrawal symptoms and a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 5 and required and took Librium for withdrawal. He still had withdrawal symptoms including diaphoresis, flushed face, tongue fasciculation, and anxiety.  There was reported excessive sweating, anxiety, and unsteady gait. He needed 24 hour treatment as he was at high risk for worsened withdrawal symptoms including life threatening withdrawal symptoms if not in this 24 hour setting at that time. The subsequent days of the admission were denied because there were no reports of withdrawal or detoxification medication. Notes reported that he had no acute events, that the alcohol withdrawal resolved, and he no longer required detoxification medication.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:Non-small cell lung cancer
Treatment:Genetic Testing (Guardant 360 panel)

Summary:
The Guardant 360 panel is not likely to be more beneficial.
There are no peer-reviewed published clinical studies of the use of the Guardant360 assay to direct therapy of non-small cell lung cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:Non-small cell lung cancer
Treatment:Genetic Testing (Guardant 360 panel)

Summary:
The Guardant 360 panel is not likely to be more beneficial.
The only appropriate testing to perform for a diagnosis of NSCLC (Non-small cell lung cancer) is ALK, EGFR ROS1, BRAF and PDL1.  These had previously been performed and were found to be negative.  There is no evidence to support Guardant 360 testing upon progression.  There is no evidence to support multiple NGS panel testing in the management of NSCLC.  The SHIVA study has shown that the use of NGS panel testing in patients with advanced cancer is of no clinical benefit.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:Non-small cell lung cancer
Treatment:Genetic Testing (Guardant 360 panel)

Summary:
The Guardant 360 panel is likely to be more beneficial.
Guardant is one of several panels of tumor markers designed to give the oncologist an option of treating in a personalized manner directed to the specific markers that the cancer expresses. It is a clinical diagnostic test based on sequencing 72 genes, and Guardant claims to be highly accurate in identifying genomic alterations
Appeal type: Medical necessity
Decision: Upheld

The patient, who has a past medical history of gastroesophageal reflux disease and dementia, presented to the hospital with complaints of erythematous and edematous left foot.  The patient failed outpatient Keflex for 3 weeks with worsening appearance of the left lower extremity.  The patient continued with swelling and tenderness to palpation with worsening erythema of the foot.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  Based on the available information, this patient's clinical presentation and plan of care, she did not require an inpatient level of care.  The necessary treatment could have been provided at a lower level of care.  The patient had incision and drainage at bedside by podiatry with some purulent discharge elicited.  The patient was started on IV antibiotics and continued with clinical improvement of cellulitis.  The patient had MRI of the foot the following day with no evidence of osteomyelitis.  The vital signs, labs remained stable and the patient was considered stable for discharge home.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension, hyperlipidemia and a family history of coronary artery disease. On 1/3/19, he presented to the emergency department complaining of sharp midsternal chest pain and diaphoresis. The pain had been present for more than 12 hours and was somewhat exacerbated by movement.

The health plan's determination is upheld. The inpatient stay is not medically necessary. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be both safe and effective and is in accordance with the 2014 AHA/ACC (American Heart Association/American College of Cardiology) Guideline for the Management of Patients With NonST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

The patient presents for the evaluation and treatment of tooth #10. Provided for review are previous letters of appeal and denial, peri-apical radiographic images from 5/18/18, periapical images of tooth #10 from unknown dates, letters from the patient, and a narrative provided by the treating provider. In question is the medical necessity of the planned treatment of porcelain crown (2750) for tooth #10.
The health plan's determination is upheld. Placing a crown on tooth #10 will result in removal of tooth structure which will weaken the tooth in order to allow for crown placement. In addition, there currently are no indications for crown coverage as there is no recurrent decay with the current direct restorations. Considering the diagnosis offered of Internal root resorption, the typical therapy would be root canal therapy in order to arrest the process. In this situation, there is not enough remaining tooth structure to allow for any further removal if internal tooth structure, which eliminates the ability to treat the tooth. As the tooth has lost a majority of the root structure and considering that there cannot be any treatment to address the diagnosis of internal root resorption the tooth has a poor prognosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment; decubitus ulcers
Treatment: Personal Care Aide - seven days 24 hours a week (live-in) 
The personal care aide - seven days 24 hours a week (live-in) is medically necessary.

The patient is a male who lives alone in a two story house.  The patient's son lives in the basement apartment. The patient is alert and responsive to stimuli.  However, he is oriented to self only.  Cognition impairment is consistent with Parkinson's induced dementia.  The patient is not able to self-direct in care and not able to make needs known.  The patient is unable to respond appropriately to simple questions.  Frequently the patient gets loud and screams when things are done for him that he does not like and/or requests.  The patient is unable to ambulate safely and requires continuous assistance by personal care assistants (PCA). 
The patient requires assistance with all activities of daily living (ADLs) and independent (i)ADLs due to cognitive impairment, difficulty walking, Parkinson's dementia and generalized weakness.  The patient's son prepares all medications and administers all medications to the patient.  The patient requires daily bathing due to his incontinence and the need for personal hygiene, changing clothes and redressing throughout the course of the day secondary to the patient's incontinence.  The patient frequently refuses care and becomes combative.  The patient is unstable with weight bearing and ambulation.  The patient has a weak and unsteady gate with a shuffling gate when walking with PCA. The patient requires wheelchair activity.  The patient requires turning and repositioning in bed every two hours as part of his skin and wound care assessment.  The patient currently has stage II and stage III decubitus ulcers which require change in position every two to three hours.  Recently, the patient has also been increasingly noted to have difficulty with swallowing.  Food requires mechanical preparation.  The patient is at significant risk for aspiration and requires feeding.  
The PCA services are expected to be more beneficial to the patient over skilled nursing facility (SNF) as the patient will be receiving one on one (1:1) care with PCA services. 
For the patient to reside in his home, it is medically necessary for 24/7 365 days per year of PCA care.  The patient's care plans for wound care, incontinence and immobility requires skilled care 24/7 as the patient's behavior is unable to be planned for.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder, Anxiety suicidal ideation

Treatment: Residential mental health treatment

The insurer denied mental health residential treatment. The decision was reversed

This patient was admitted to mental health residential treatment due to depressive and anxiety symptoms, suicidal ideation, poor coping skills, and reports of eating disorder symptoms.  She had reports of past suicide attempts.  She had diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, and Eating Disorder.  She went to this facility from Intensive Residential Dialectical Behavioral Therapy (DBT) treatment.  She had past psychiatric hospitalizations in 2008 and had partial hospital program treatments in 2010, 2011, and 2013.  It was reported that she had a three month residential treatment stay in 2013 and then after her first two suicide attempts, she had a psychiatric hospitalization in 2013.  She was in McLean Hospital's Intensive Residential DBT treatment for three months prior to this admission of 23 months.  She was discharged.

This patient was considered a high risk patient due to her two past suicide attempts, depressive and anxiety symptoms, eating disorder symptoms, and poor coping skills.  She required a significant time in this inpatient therapeutic residential treatment setting to try to learn better coping skills, improve insight and decision making, better control emotions, and sustain gains and further progress so that when finally discharged from 24 hour treatment, she could have the best chance of not regressing and making other suicide attempts.  Suicide attempts are the single most reliable indicator for suicide and this patient had past suicide attempts with poor coping skills; therefore, she was considered a high risk for suicide. 

The patient had continued depression reported and voiced suicidal ideation and that the staff did not feel that she could be safe with the lowered supervision of the apartments. As such, she moved back to the Ranch.  Once again, she was not able to maintain a more independent living and less supervision for a sustained period of time; therefore, she required much more time in this 24 hour therapeutic residential setting.  Therefore, she still had major difficulty with coping skills interfering significantly with her functioning.  
This was a high risk patient with multiple treatments in inpatient hospital, residential and Partial Hospital Program (PHP) settings who required a long time in a therapeutic residential setting as she worsened and decompensated each time attempts were made to increase her independence.  She even had a reported suicide attempt and hospitalization while in this residential setting during the denial period, so she required at least this inpatient mental health residential treatment.
Appeal type: Medical necessity
Decision: Upheld

This is a female patient who was receiving ongoing physical therapy/manual therapy for the treatment of lumbar intervertebral disc displacement. These visits represent visits #7 through #13 for the same condition. According to a physical therapy note, the patient reported her back was much better after the recent injection and the patient was no longer feeling any pain down the leg. A physical exam was not performed. It was noted there was no radicular pain throughout the session. The patient was recommended for continued therapy. Additional therapy was completed  to include manual therapy. The issue under review is the medical necessity of manual therapy times seven (x7).
The health plan's determination of medical necessity is upheld. The patient presented reporting no pain down the leg and reported feeling much better after the recent injection. There were no specific objective deficits on examination on that visit and the patient had already received education and instruction on an independent home exercise program. The patient could have continued to progress independently to manage symptoms and improve overall strength and range of motion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic; ureteral calculus
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, or severe vomiting.  Pain control, IV antibiotics and IVF followed by ureteroscopic stone extraction and stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Hospital Services

Summary: This patient with a history of moderate persistent asthma and frequent previous hospitalizations began having difficulty breathing 2 days prior to the admission and was seen in the Emergency Room (ER) on the day prior to admission. He was discharged at that time after treatment in the ER to continue albuterol and prednisone at home. The mom was not able to pick up the prescription for prednisone and when he continued to have difficulty breathing and wheezing she brought him back to the ER. In the ER the patient was noted to be in respiratory distress with tachypnea, wheezing and retractions. Upon examination of the lung he was noted to have wheezing and a prolonged phase of expiration. He was treated with albuterol and atrovent on 3 occasions and he received an intravenous (IV) bolus of steroids. Following treatment in the ER he was noted to continue to have evidence of respiratory distress with subcostal retractions. The decision was made to admit the patient to the hospital with a diagnosis of status asthmaticus. The plan was to continue treatment with albuterol and steroids.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was reversed.

The patient was treated appropriately in the ER for asthma with wheezing. He had been treated in the ER one day prior before returning to the ER in respiratory distress. He has had multiple previous hospital admissions with the last admission just one month prior to this admission. On that admission he required several days of bilevel positive airway pressure (BiPAP) in a pediatric intensive care unit (PICU) setting. In addition his mother had discontinued asthma preventive therapy. He continued to have difficulty breathing, wheezing and retractions after treatment in the ER. He had failed outpatient therapy for asthma because his mother was not able to obtain the prescribed medication. The decision to admit him to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol and steroids was consistent with the standard of care for a child of this age with status asthmaticus.
Appeal type: Medical necessity
Decision: Upheld

This patient, with chronic otitis media, was scheduled for surgery along with a three day stay for insertion of a PICC line and planning for outpatient antibiotic therapy. The health plan has denied the inpatient stay as not medically necessary. The health plan's determination is upheld. The patient underwent an uneventful procedure that did not require hospitalization. Tympanomastoidectomy is commonly performed as an outpatient procedure.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with several days of epigastric pain. Computed tomography identified infra-hepatic inflammatory lesion, possibly omental infarct. Patient underwent laparoscopic resection of infarcted appendage of the falciform ligament. Procedure was uncomplicated. The health plan's determination is upheld. The patient required urgent surgical intervention, however a lower level of care would have satisfactorily allowed for the care provided and would have been consistent with the accepted standard of medical care. The patient was clinically stable at the time of presentation and remained so during the course of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a gravida (G)1 para (P)1 female who is status post term vaginal delivery who presented from home after noting elevated blood pressures in the 170s over 100s. Her prior medical history was noted for a history of hypertension from 2013-2014 and morbid obesity. The patient presented to the emergency department and reported having no headache, no change in vision or right upper quadrant or epigastric pain. She had noted decreased urine output. She did report worsening lower extremity swelling. She was noted to have an induction for preeclampsia without severe features at 40-1/7 weeks due to newly found elevated blood pressure during her routine prenatal care visit. The patient was monitored for worsening signs and symptoms of preeclampsia and her blood pressure at the time of discharge was in the 120 to 130s over 80s. The patient was admitted for hypertension and for evaluation. She was noted to have class III obesity with alveolar hypoventilation and a body mass index of 50 kilograms per meters squared. During hospitalization, the patient was able to tolerate a regular diet and had no symptoms. Pain was well-controlled. She was ambulating and voiding without difficulty. Blood pressures were 139 and 157 or 73-86 overnight. The patient had no severe signs or symptoms. Her blood pressure been well controlled with only symptom being a headache of 5-6/10 after taking Procardia on the prior day. The patient reported after taking Tylenol for headache was resolved. Her pain was well-controlled. Moderate lochia was noted. The patient was ambulating and tolerating a regular diet. The subject under review is the medical necessity of the inpatient stay. The health plan's determination of medical necessity is upheld, in whole. This patient was previously diagnosed with preeclampsia in the recently delivered pregnancy and was still in the time period of resolution of symptoms. She was noted to have no recurrent symptoms of preeclampsia with severe features but rather required adjustment of her oral antihypertensive medications. This patient was noted to have blood pressures that were elevated. Thus, her control was optimized with dose adjustments of her oral antihypertensive regimen (Labetalol 200 mg twice a day [BID] and Procardia 30 XL). The blood pressure was readily controlled on oral medications and the patient was discharged to home. This care would not require acute inpatient care for dose adjustment of blood pressure medications. According to the Milliman Care Guidelines (MCG) Care Guidelines, this care could be provided at a lower level of care status. Thus, the inpatient level of care was not medically necessary in this case based on this documentation where there was no end organ damage, severe features, or severe range blood pressures.