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

Diagnosis: Alcohol intoxication. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This adult male with a history of alcohol abuse presented with alcohol intoxication and depression. His vital signs were stable, and he was afebrile. His heart rate was 107. The patient's exam was remarkable for tremors. Pertinent labs revealed an alcohol (EtOH) level of 346. He was admitted with alcohol withdrawal. The plan of care included intravenous fluids and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. The patient remained hemodynamically stable. There was no evidence of 
severe withdrawal or need for excessive amounts of benzodiazepines. He was discharged on day #3. 

The proposed treatment is not medically necessary. 

This patient was admitted after presenting with alcohol intoxication. The patient was hemodynamically stable and afebrile. He did not have vomiting, delirium, or seizures. His exam showed tremor. Labs were remarkable for alcohol intoxication only. The patient was admitted with plan for intravenous hydration and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. The patient remained clinically stable without signs of severe withdrawal. He did not have symptoms that required an acute inpatient level of care. He had not failed management at a lesser level of care. Inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure

Treatment: continued hospital admission

The insurer denied coverage for continued hospital admission

The denial is overturned
 

The patient is an adult female with a history of ovarian cancer who was on Chemotherapy. She presented to the hospital with complaints of chest tightness and shortness of breath (SOB) and orthopnea. Physical examination revealed Jugular Vein Distention, rales on lung auscultation and pedal edema.

Laboratory results were notable for elevated Brain natriuretic peptide (BNP), anemia and Renal Insufficiency/ acute kidney injury. 

The patient was admitted with diagnosis of new onset Acute Heart Failure likely secondary to chemotherapy induced cardiomyopathy. She was admitted to Telemetry and started on intravenous (IV) diuretics. She was seen by Cardiology, Hematology and Renal services. Myocardial Infarction was ruled out and an echo cardiogram confirmed a diagnosis of Congestive Heart Failure with reduced Systolic Function with Ejection Fraction at 35 percent.

The patient was initiated on Carvedilol and angiotensin-converting enzymes (ACE) inhibitors were held due to acute kidney injury. She remained symptomatic with electrolyte imbalances which were treated. The patient was on daily weights and strict In & Out fluid monitoring, and Basic Metabolic Panel monitoring twice per day. The patient's diuretic dose was increased to improve diuresis.

The patient was on high doses of intravenous (IV) Lasix and Renal Function needed close monitoring due to risk of Cardio Renal Syndrome. Patient was on intravenous (IV) Lasix. During hospital stay the patient was noted to have worsening anemia with increased lactate dehydrogenase (LDH) and Schistocytes. The possibility of Thrombotic Microangiopathy was considered.

The patient's cardiac meds were adjusted to optimize cardiac function. Hemolytic anemia was being ruled out. Renal function was closely monitored and stabilized. Once stabilized the patient was cleared for discharge on oral medications with close follow up in the outpatient setting.

Given new onset Heart Failure with multiple other co-morbidities it was appropriate for the patient to remain in the hospital for the period in question. This patient needed very close monitoring while diuretics and cardiac medications were adjusted. It would not have been safe to do it in any other setting.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the continued hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Dementia
Treatment: Home health care

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift). The health plan's determination is upheld. 

This is a case review for a female with medical history notable for dementia, arthritis, and congestive heart failure. The patient and her care team requested an increase in personal care services to 24 hours per day (2-12 hour split-shift). A Uniform Assessment System (UAS) was completed and was available for review. The patient's daughter was present for the assessment. The assessment was conducted in a nursing facility where the patient was receiving rehabilitation. The patient was alert and oriented to person only; decisions are consistently poor and unsafe. For her Instrumental activities of daily living (IADL), she requires total dependence for nearly all. For her ADL's, she requires total dependence for bathing, locomotion, and toilet use. She requires maximal assistance for dressing upper body and toilet transfer. She requires extensive assistance for all others. She is frequently incontinent of urine and stool. Compared to a prior UAS, she showed a functional and cognitive decline.

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift) is not medically necessary for this patient.

The patient is approved for 24 hour live-in care. The care team requested an increase to 24 hour split-shift care. Live-in aides are expected to receive adequate rest, including a minimum of 5 hours of uninterrupted rest at night. The question at hand is whether the patient has personal care needs that would preclude a 5 hour rest window at night for the live-in aide.

The documentation provided does not demonstrate that the patient's personal care needs would preclude this rest window. She does require hands-on assistance for all activities of daily living (ADL), but the live-in aide should be able to address these. There were no night-time logs provided. She does not have any pressure ulcers that require turning and repositioning. It has not been clearly demonstrated that split-shift personal care is medically necessary. The patient does have some dementia-related behaviors at night, but personal care hours are not approvable for safety monitoring and security in the absence of a personal care function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ingrown toenail. 
Treatment: Custom shoe insert (L3020 x 1). 
The insurer denied coverage for the custom shoe insert (L3020 x 1). 
The denial is upheld. 
 
The patient presented to the office for a left ingrown toenail. The physical examination revealed tenderness and erythema to the bilateral medial hallux nail folds, as well as findings consistent with pes planus. The affected nail borders were debrided without incident. Custom orthoses were recommended as a statement was made that the flat foot deformities were contributing to the formation of the ingrown nails. The request is for custom orthoses, which is under medical necessity review.

Per the Milliman Care Guidelines (MCG) Foot Orthotics, Custom 26th Edition ACG: A-0342 (AC) "Custom Foot Orthotics may be indicated when all of the following are present: 

- Arch, heel or other foot pain 
- Foot condition, as indicated by one or more of the following: 
- Diplegic cerebral palsy 
- Juvenile idiopathic arthritis 
- Pes Cavus (high arch) 
- Plantar fasciitis, with all of the following: 
- Adjustment of activities failed to improve symptoms 
- Anti-inflammatory medications failed to improve symptoms 
- Prefabricated orthotics failed to improve symptoms 
- Stretching of calf muscles and plantar surface failed to improve symptoms 
- Symptoms are present for 3 or more months 
- Posterior tibial tendon dysfunction in adult as indicated by one or more of the following: 
- Stage I disease (tenosynovitis without deformity) 
- Stage II disease (flexible and passively correctable deformity) 
- Rheumatoid Arthritis." 

The patient does not meet the MCG Foot Orthotics, Custom 26th Edition ACG: A-0342 (AC) guidelines. The patient was not diagnosed with a condition that meets policy criteria for custom orthoses. 

Medical necessity has not been established. There is no documentation of a trial and failure of over the counter orthoses to treat the patient's condition. Therefore, the custom shoe insert is not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for custom shoe insert (L3020 x 1) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: cellulitis
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a previously healthy male who presented to the emergency department (ED) with a 1 day history of swelling and warmth of the right upper extremity. He has a cat at home and has a scratch on the area of hand swelling with some associated papules. There has been no fever.

The inpatient hospital stay was not medically necessary. This otherwise healthy child presented with cellulitis of the right upper extremity. He had normal bloodwork and no fever. There was no vomiting or inability to tolerate oral medication. Given the severity of the redness, swelling, and warmth, he was started on IV antibiotics prior to transition to oral medication. This could have been safely performed at a lower level of care to monitor initial response, with subsequent discharge to home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatic encephalopathy. 
Treatment: Long term custodial care. 
The insurer denied: Long term custodial care. 
The denial is upheld. 

This adult male patient has a history of alcohol abuse and hepatic encephalopathy. He was approved for a long-term custodial care level of care for approximately 5 weeks five months ago. At that point, the patient remained at this level of care for restorative physical therapy (PT) / occupational therapy (OT). He was clinically stable. His oral medication regimen was established. Lactulose was being adjusted based on ammonia level.

The proposed treatment is not medically necessary. 

Custodial care is care primarily for the purpose of assisting a patient in activities of daily living or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury. It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value. Such care includes assistance with walking, bathing or dressing; transfer or positioning in bed; normally self-administered medicine; meal preparation; feeding by utensil, tube or gastrostomy; oral hygiene; ordinary skin and nail care; catheter care; suctioning; using the toilet; enemas; or preparation of special diets and supervision over medical equipment or exercises or over self-administration of oral medicine. The information provided does not support the necessity for assistance with activities of daily living or personal needs. 
The patient does not have an impairment(s) that prevent him from caring for himself. The information provided does not support that the patient requires a custodial level of care for assistance with activities of daily living. Long term custodial care requested is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Upheld

Patient is a male with past medical history significant for hypertension (HTN), coronary artery disease (CAD), obesity, hyperlipidemia, and right knee arthroscopy who presented to the Emergency Room (ER) with complaints of right leg pain and swelling. 

Vital signs on presentation included: Temperature -98.4 degrees Fahrenheit, Blood Pressure -154/113, Pulse -98, Respiratory Rate -16, oxygen (O2) saturation -100%. Laboratory results were remarkable for: White blood cell (WBC) -6.7k, hemoglobin (Hgb) -14.5, hematocrit (Hct) -46.4, creatinine -0.89, glucose -87.

Patient was empirically started on intravenous (IV) antibiotics (Vancomycin). Radiographic image (x-ray) of the knee showed no fracture, but a supra-patellar effusion that is not well defined. Orthopedics consulted and performed an arthrocentesis. Results were not indicative of septic arthritis. Their impression was likely postsurgical reactive inflammatory changes and bleeding. Patient remained afebrile and hemodynamically stable. He was discharged to monitor off antibiotics.

According to documentation, patient was admitted to hospital for right knee pain. Otherwise, he was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. Orthopedic surgery performed an arthrocentesis and septic arthritis was deemed unlikely. Based on above findings, patient met criteria for observation level of management. He did not meet criteria for acute hospitalization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ureteral calculus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Reviewer Findings:

This adult male presented to emergency department with complaints of nausea and abdominal pain. The patient was afebrile, hemodynamically stable in the emergency department. Computed tomography scan revealed a calculus in the distal ureter without hydronephrosis. Patient was admitted, given intravenous fluids, pain medications, Flomax. He declined Urologic intervention, he improved, and was stable for discharge. Per Milliman Care Guidelines Health (26th) Renal Colic and Kidney Stones, patient fails to meet guidelines for admission to inpatient care. These include hemodynamic instability, urinary tract infection, acute kidney disease or acute renal failure, bilateral obstruction, obstruction of patient's solitary kidney, etc.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Percutaneous Implantation Neurostimulator Electrode.

The insurer denied Percutaneous Implantation Neurostimulator Electrode.  The health plan's determination is upheld.

The patient is a female with complaints of low back pain. She has nonspecific radiation of pain into the legs intermittently. She has exhausted physical therapy and continues with home exercises. Medications have been trialed, without any efficacy. The patient has had multiple prior injections, including epidural injections. Pain is constant, and aching. Pain ranges from 8-9 out of 10. Physical exam demonstrated lumbar spine negative straight leg raise bilaterally, mild hypoesthesia in the right lower extremity nonspecific. Lumbar magnetic resonance imaging (MRI) shows small bulge with ligamentous facet hypertrophy which stenosis at L (lumbar)5-S (sacral)1. The patient underwent a clinical neuropsychological evaluation. 

The Percutaneous Implantation Neurostimulator Electrode is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Spinal cord stimulation involves implanting a spinal cord stimulator lead into the epidural space, either percutaneously or by surgical laminectomy or laminotomy. Electrical impulses are generated by a pulse generator that is implanted subcutaneously. These electrical impulses generate stimuli that mask sensations of pain.
A specialty society guideline evaluating the appropriate use of spinal cord stimulation for the treatment of chronic pain and ischemic disease supports the use of spinal cord stimulation for the treatment of failed back surgery syndrome and complex regional pain syndrome in patients with the following characteristics: chronic neuropathic pain, favorable psychological evaluation, improvement in symptoms with percutaneous test stimulation prior to device implantation, and absence of contraindications such as coagulopathy or infection. 
In this case, the patient has lumbar radiculopathy. A spinal column stimulator is not supported in this clinical scenario. The patient does not have a clinical condition for which a lumbar spinal column stimulator may be supported, such as failed back surgery syndrome, or complex regional pain syndrome critical limb ischemia, or chronic angina pectoralis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Percutaneous Implantation Neurostimulator Electrode.

The insurer denied Percutaneous Implantation Neurostimulator Electrode.  The health plan's determination is upheld.

The patient is a female with chronic low back pain failing epidural steroid injection (ESI), radiofrequency ablation (RFA) treatments, and other conservative routes. An magnetic resonance imaging (MRI) lumbar spine shows L (lumbar) 5-S (sacral) 1 degeneration with stenosis. Under review is a Percutaneous Implantation Neurostimulator Electrode.

Percutaneous Implantation Neurostimulator Electrode is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There is no indication of failed back surgery syndrome as no prior surgery was noted, nor complex regional pain syndrome (CRPS). Therefore, the appropriate indications for a stimulator have not been met.
Cohen et al. noted " In this large, real-world, comparative effectiveness research study comparing spinal cord stimulator (SCS) and CMM (conventional medical management) for chronic pain, SCS placement was not associated with a reduction in opioid use or nonpharmacologic pain interventions at 2 years. SCS was associated with higher costs, and SCS-related complications were common."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Percutaneous Implantation Neurostimulator Electrode.

The insurer denied Percutaneous Implantation Neurostimulator Electrode.  The health plan's determination is overturned. 

This is a female with a history of chronic neck, low back and leg pain. She has had physical therapy, injections and medications without relief. She is a non-smoker. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows multilevel degenerative disc disease. The patient had a favorable neuropsychological evaluation. 

The Percutaneous Implantation Neurostimulator Electrode is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The literature supports spinal cord stimulator (SCS) for treatment of chronic low back pain in patients who have not undergone surgery and have failed conservative therapy.
Vallejo et al. cite, "Spinal cord stimulation for the treatment of chronic pain is rapidly evolving with technology at its forefront. This comprehensive focused review evaluated 11 randomized controlled trial (RCT) and 7 nonrandomized/observational studies which provided levels of evidence ranging from I to II". Eckermann et al. cite, "Findings suggest that SCS is a promising, safe, minimally invasive, and reversible alternative option for managing chronic back pain in patients who have not undergone spinal surgery". Al-Kaisy et al. cite, "In conclusion, our analysis showed that 10 kHz spinal cord stimulation reduced pain, disability and opioid consumption in those living with non-surgical refractory back pain". Aryal et al. cite, "The authors conclude that spinal cord stimulation therapy can be used to manage chronic low back pain, other neuropathic pain, and ischemic pain when other standard treatment methods have failed and the pain persisted for more than six months".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with a history of hypertension, coronary artery disease post-stent placement, urinary incontinence, and fecal incontinence who presented to the Emergency Department. He complained of severe pain in the left flank, both groins and suprapubic areas, with occasional radiation of pain from the left flank to the left groin. The pain was initially relieved with emergency department (ED) -administered pain medications. When seen by the admitting physician, the patient reported mild pain only in the suprapubic region. 

The inpatient hospital admission was not medically necessary for this patient.
The patient presented to the hospital with suprapubic and groin pain. However, the pain was not associated with hemodynamic instability or peritoneal signs on exam. The pain significantly improved after administration of intravenous medications in the emergency department. The imaging studies revealed no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction. There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon. The evaluation of pain did not require the patient not to eat or drink for an extended period of time.
The patient had mild colitis or mild diverticulitis, which generally does not require admission to the hospital at the acute inpatient level of care. Initial treatment with intravenous antibiotics with subsequent transition to oral antibiotics could occur at a lower level of care.