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

Diagnosis: Schizophrenia

Treatment: 46 units of Inpatient Mental Health Treatment

The insurer denied the 46 units of Inpatient Mental Health Treatment. The denial was reversed.   

This is a male patient who was brought to the Emergency Department (ED) by emergency medical service (EMS) with psychotic episodes. The patient had a history of multiple psychiatric hospitalizations for schizophrenia. He was evaluated by psychiatry. He was noted to be paranoid, hostile, agitated and was talking to himself. He denied suicidal and homicidal ideations. It was reported by his mother that the patient's behavior was erratic and that he had not taken his medication in a year. During his admission the patient continued to experience psychotic symptoms such as suspiciousness, anxiety, irritability, and anger. The patient was treated with Clozapine and Haloperidol decanoate. Due to the patient's increasing delusional symptoms throughout his six week hospital stay, his medications were increased accordingly. It was noted that the patient did have a positive respond to the treatment plan. The patient was discharged to a long term care inpatient facility because he could not be safely discharged to the community.

Based upon the information available the patient medically required continued acute inpatient psychiatric treatment. The patient continued to display severe and acute symptoms of schizophrenia, including acute psychosis and disorganized behavior, despite appropriate and ongoing psychiatric treatment. There were no safe alternative settings for the patient other than a long-term inpatient hospital setting. The appropriate setting could not be utilized until the day of his discharge.  

This finding is consistent with the general standards of psychiatric care and the American Psychiatric Association (APA) Guidelines for the Treatment of Patients with Schizophrenia.

The carrier's denial of continuation of coverage for 46 units of Inpatient Mental Health Treatment is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hereditary lymphedema and lymphedema, not elsewhere classified

Treatment: Pneumatic compression device

The insurer denied coverage for pneumatic compression device.  The denial was reversed. 

This patient is a female with diagnoses of hereditary lymphedema and lymphedema, not elsewhere classified.  Treatments included home therapy with bandaging, garments, exercise and elevation.  A basic pneumatic device was tried and failed due to resultant truncal and genital swelling.  The Flexitouch Pneumatic Compression Device was trialed and resulted in decreased extremity swelling and pain as well as improved functional ability.  Currently under review is the denial of coverage for the pneumatic compression device provided.    

The submitted documentation indicates  "Per the prescription for pneumatic compression device Flexitouch system, the patient tried home therapy with bandaging, garments, exercise and elevation for at least 4 weeks; treatment failed to effectively control the patient's symptoms."  The prescription for pneumatic compression device Flexitouch system is considered part of the medical record.  

Based on the patient's medical record documentation of successful trial use for this device, medical necessity standards and scientific data, the proposed pneumatic compression system has been proven to be safe and effective.  The requested pneumatic compression system should not be considered unproven for this patient's medical (lymphedema) condition.  In this particular case, given improvement demonstrated by the Flexitouch pneumatic compression device, after prior treatment failure with a basic pneumatic device, the service is medically necessary.  

The health plan did not act reasonably with sound medical judgment for in the best interest of the patient for this particular case.  The pneumatic compression device provided is considered medically necessary for this patient's clinical condition.

Based on the above, the medical necessity for the pneumatic compression device provided on is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient was referred to a residential mental health treatment facility in order to address severe symptoms of major depressive disorder. The admission to residential care was immediately after an acute inpatient hospitalization for a suicide attempt by overdose of medication and alcohol. The health plans determination is overturned.
The patient's admission and continued residential level treatment was reasonable and in the best interest of the patient; he continued to display clinical features and symptoms that necessitated/warranted residential level services as he struggled to engage in treatment and had intermittent bouts of affective instability that did require residential level structure and monitoring with active treatment. In this case, the patient could not have been safely or effectively managed in a less restrictive environment for the dates-of-service under review. The continued residential structure, monitoring and intensity of services were warranted in this case scenario in view of the treatment factors and presenting clinical features that included safety risks, and severe symptoms of multiple psychiatric disorders including attention deficit hyperactivity, mood and anxiety disorders and substance use disorders that were associated with affective instability and impaired functioning, as well as treatment failure at lower levels of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has severe severe maxillary and mandibular crowding. Tooth #10 is in crossbite and tooth #29 is impacted and blocked out. Orthodontic treatment to correct this malocclusion is being requested.

The health plan's determination is overturned. The Periodic Orthodontic Treatment [D8670] is medically necessary for this patient.
The patient has significant maxillary and mandibular anterior crowding, with tooth #10 in crossbite. This tooth is at high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Further labial movement of the lower incisors will likely lead to the need for future for periodontal grafting on this tooth.
Additionally, tooth #29 is impacted. Approximately 10% of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology.5 The two most common types of pathology caused by impacted teeth are periodontal bone loss and root resorption of adjacent teeth. If left untreated the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem.
Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cough
Pharmacy/Prescription Drugs

The patient is a female with a dry persistent cough without fever. No other information is provided. Hydromet Syrup is being requested and is under review. 

The health plan's determination is upheld. Hydromet Syrup is not medically necessary. A number of agents, both opioid and non-opioid, are thought to suppress cough via an action on the central cough center. Although data are limited regarding efficacy despite widespread use, usual treatment is to start with dextromethorphan or guaifenesin, due to its better side effect profile. For patients who have a cough due to an unrelenting cause or a persistent cough despite both specific therapy and nonspecific therapy with non-opioid agents, codeine or long-acting morphine are tried, recognizing the risk of addiction and other narcotic-related adverse effects. The use of Hydromet syrup as a first line agent for an acute cough is not consistent with current health care practice guidelines and standards that are endorsed by professional health societies. Therefore, the Hydromet Syrup is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

CHARGE Syndrome
Nursing Services (including Private Duty Nursing)

The patient is a male infant born at 37 weeks' gestation with complex medical history including CHARGE syndrome, pelvic kidney with chronic renal disease, large ureterocele with grade V vesicoureteral reflux status post right nephrostomy tube placement, history of tracheoesophageal fistula status post repair, anemia of renal disease, dextrocardia, gastroesophageal reflux, tethered cord, choledochal cyst, history of duodenal obstruction status post repair, and right choanal atresia. He was hospitalized in the Neonatal Intensive-Care Unit (NICU) from birth. His treatment team includes Nephrology, Urology, Cardiology, Audiology, Genetics, Pulmonary, ear, nose, and throat (ENT), Pediatric Surgery, Ophthalmology, Gastroenterology, Neurosurgery, Neurodevelopmental Pediatrics, and Interventional Radiology. He receives feedings via pump every three hours for seven total feedings in the day. He receives multiple medications during the day including one injectable medication. He lives with his parents and toddler brother, and his parents have been trained in his care.

The health plan's determination is upheld. The requested skilled nursing care 24 hours per day 7 days per week is not medically necessary for this infant. This young male infant has a very complex congenital medical condition, with abnormalities in multiple systems. However, he has been stable since prior to discharge home, receiving gastrostomy tube feedings every three hours (decreased from eight to seven feedings daily to allow for undisturbed sleep), nephrostomy tube care, and medication administration. All of these needs can be provided by trained caregivers; both of his parents have been trained in his care. At this time, his needs do not justify or necessitate the skilled home nursing services.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with normal Class I occlusion in the late mixed dentition. There is minor crowding of the upper incisors and moderate crowding of the lower incisors. Coverage for orthodontic treatment was denied as the case failed to meet the standards for medical necessity.

The health plan's determination is upheld. 

No, the requested treatment of braces and monthly visits are not medically necessary for this patient.
This case is a normal Class I occlusion in the late mixed dentition with minor crowding of the upper incisors and moderate crowding of the lower incisors and does not qualify as medically necessary according to the standard guidelines stated in the Handicapping Labio-Lingual Deviation (HLD) malocclusion index.
According to the HLD malocclusion index, medical necessity requires congenital dentofacial abnormalities such as cleft lip and palate, impinging overbite with palatal soft tissue damage, crossbite of individual anterior teeth, or severe facial skeletal deviations secondary to facial trauma. In the absence of these four automatic qualifiers, medical necessity requires a combination of three variables: 1) severe skeletal discrepancy in the sagittal, vertical or transverse dimension; 2) severe tooth size arch length discrepancies (crowding) and 3) posterior or anterior crossbite.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of neuroendocrine carcinoma of the pancreas status post Whipple complicated by pancreaticojejunostomy stricture followed by leak, recurrent pancreatitis requiring multiple endoscopic retrograde cholangiopancreatographies with stent placements; she also had gastroesophageal reflux disease (GERD) and iron-deficiency anemia. She presented to the emergency department on with a history of progressive worsening constant right upper quadrant abdominal pain, weakness, nausea, and one episode of emesis. Her pain was similar to prior episodes of pancreatitis, and worse on lying flat, and improved when bending forward. She had attempted Tylenol and Advil without improvement.
Physical examination was notable for right upper quadrant and epigastric abdominal tenderness and bilateral costovertebral angle tenderness. Lab results were notable for anemia with hemoglobin of 10.9 grams per deciliter (g/dL), elevated potassium of 5.3 millimoles per liter (mmol/L), and normal lipase of 20 units per liter (U/L). A computed tomography scan of the abdomen and pelvis showed hepatomegaly and prior Whipple procedure; there were no acute findings. A computed tomography scan of the chest showed multiple bilateral pulmonary nodules measuring up to 3 millimeters (mm), unchanged since a prior scan. The health plan's determination is upheld. The patient had possible acute pancreatitis, as the lipase may be normal during pancreatitis after a Whipple procedure [1-4]. Notably, imaging did not show pancreatitis or complications of pancreatitis such as peripancreatic fluid collections. The patient was appropriately treated, with intravenous fluid administration and gradual advancement of diet [5]. However, there was a lack of hemodynamic instability, organ failure, pleural effusion, or other sequelae to justify acute continued inpatient care, and the treatment provided could have been provided without the acute inpatient level of care [6]. The Gastroenterology consultation did not recommend further inpatient workup for pancreatitis and signed off on the day of admission with a recommendation for advancing diet as tolerated and Pain Management consultation. Pain management recommended resumption of home oral pain medications, which could have been completed by the second day of admission and did not require the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck/back pain post car accident

Treatment: air medical transport

The insurer denied coverage for air medical transport. The denial was reversed.

This patient is a woman with several medical problems who had a car accident.  She was the driver.  She did not remember the accident when found by Emergency Medical Services (EMS).  It was apparently difficult to extricate her from the car.  She complained of neck/back pain and there was concern for a spinal cord injury.  She had an abnormal-looking clavicle and pain.  Her vital signs were normal.  She was taken by air ambulance to the nearest hospital.  Her insurance denied payment for this, stating she was medically stable.  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The patient was in a serious car accident and required care in hospital.  The EMS team used their clinical judgment to decide that air transport was the best option to get her there.  

The air medical transport is considered medically necessary for this patient.  While the patient turned out to only have a few broken ribs, there was no way for the EMS team at the scene to know this with certainty.  By description, it was a high-risk auto accident.  A chest/clavicle deformity was noted.  She was amnestic for the event.  The hospital was over an hour away by ground.  These features meet criteria for emergency air transport to a hospital. 1 CDC guidelines for the field triage of injured patients state "when in doubt, transport to a trauma center."2  There is no evidence that the decision to use air transport was based on anything other than appropriate concern about the patient's medical condition and need to get her to a hospital quickly.

The carrier's denial of coverage for the air medical transport is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical shortening

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial was upheld.

This patient is a female who was admitted at 24.2 weeks gestation because of cervical shortening. The patient had been maintained on vaginal progesterone and followed up with cervical length measurements. The patient received magnesium sulfate for neuroprotection and Celestone for lung maturity. She was discharged home following her second dose of Celestone.

The patient had a short cervix.  She was admitted and placed on magnesium sulfate and received steroids. The patient was already receiving vaginal progesterone. The patient was not in labor.

The value of hospitalization for women with short cervix has been studied and the scientific literature showed that admission to the hospital was not associated with a decreased rate of preterm delivery and there was a trend toward hospitalization as an independent risk factor for delivery at < 34 weeks, an earlier gestational age at delivery, and a shorter time from diagnosis to delivery. Hospitalization was independently associated with an increased rate of cervical shortening. Another study showed that activity restriction did not reduce the rate of preterm birth in asymptomatic nulliparous women with a short cervix.

The patient did not have any contractions. The fetal heart was reassuring. She was afebrile. She had three previous term deliveries. She could have been followed as an outpatient with serial ultrasound monitoring of her cervical length.

In summary, the inpatient admission was not medically necessary.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Carcinoma in situ of the cervix

Treatment: Inpatient hospital admission 

The insurer denied coverage for Inpatient hospital admission. The denial was upheld.

This patient is a female who was admitted for surgery, due to a diagnosis of carcinoma in situ of the cervix. She underwent a robotic-assisted laparoscopic hysterectomy and bilateral salpingectomy. The procedure was reported as uncomplicated. The estimated blood loss (EBL) was 50cc. The post-operative progress note documented that the patient was stable with no complaints. The patient was discharged to home.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Robotic assisted hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to MCG, Laparoscopic Hysterectomy, a laparoscopic 
hysterectomy is an ambulatory procedure. The Inpatient stay may be needed for:
1) Surgical complications (bladder ureter or bowel injury or hemorrhage), 2) Conversion to abdominal hysterectomy, 3) Complex surgery (staging of endometrial cancer), 4) Wound complications, 5) Comorbidities.

This patient did not meet any of these criteria. Her procedure was uncomplicated. Post operatively, the patient was stable. 

Nothing in the progress notes suggested any serious problem that warranted admission.  Please note that a robotic assisted laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

Based on the above, the inpatient admission was not medically necessary. The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Activities of daily living dependence; blindness
 
Treatment: Personal care aide services

The insurer denied the personal care aide services. The denial was reversed.

The Uniform Assessment System (UAS) states this is a male patient who currently resides in a skilled nursing facility, pending discharge to the community.  The patient has a history of diabetes mellitus, peripheral vascular disease (PVD), glaucoma, diabetic retinopathy, blindness, atherosclerotic heart disease, congestive heart failure, atrial fibrillation, pacemaker, hypertension, hyperlipidemia, ESRD on renal dialysis, depression, anxiety, and insomnia. His memory has declined and he needs maximal assistance with bathing, dressing lower body; extensive assistance needed for personal hygiene, dressing upper body, walking, locomotion, and toilet use.  

The patient lives with his son, and his daughter lives upstairs. It is not clear whether either the daughter or the son will be available to provide assistance on a regular basis if the patient returns home. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. 

The patient has several medical conditions that affect his daily life, including ESRD with hemodialysis 3 times per week, cardiopulmonary disease that requires daily oxygen use, severe PVD with open wounds on his foot, and he is blind. Recent records indicate the patient has decreased endurance, limited exercise tolerance, pain, non-weight bearing on left lower extremity. These physical restrictions, his vision loss, and possible cognitive impairment all contribute to the need for assistance with all daily activities throughout the day and night. The patient's physical limitations and vision impairment place the patient at high risk for falls and accidents if he is left alone to perform daily activities. 

Based on the current available information, 24-hour PCA services provided as two 12 hour split shifts is medically necessary to address the patient's daily needs.  The medical necessity for Personal Care services, 24 hours a day, 7 days a week (split-shift), total of 168 hours a week is substantiated.  The insurer's denial is reversed.