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

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

The patient presented to the emergency department after a two hour episode of chest pain with radiation to the jaw and neck and associated dyspnea and palpitations. He had a history of hyperlipidemia and a family history of premature coronary artery disease. His blood pressure was 130/70 millimeters of mercury (mmHg) with a heart rate of 75 beats/minute. His electrocardiogram showed sinus rhythm without acute changes. His serum troponin level was .234 and rose to .766. The patient was treated with enoxaparin and clopidogrel and admitted to the hospital with a suspected non-ST segment elevation myocardial infarction. He was transferred to another institution for cardiac catheterization. At issue is the medical necessity of an inpatient stay. 

An inpatient stay was medically necessary. 

This patient, with known cardiac risk factors, presented with chest pain and an abnormal, and rising, serum troponin level, suggesting a diagnosis of non-ST segment elevation myocardial infarction (NSTEMI). Based on his HEART [History, Electrocardiography, Age, Risk factors, Troponin] score his risk for major adverse cardiac events, including shock, death, congestive heart failure and malignant arrhythmias, was 12-16.6%. Current guidelines, including the 2014 American Heart Association (AHA)/ American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes and the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR)Guideline for the Evaluation and Diagnosis of Chest Pain recommend inpatient admission for patients with NSTEMI. 

Per the Milliman Care Guideline, Chest Pain (ORG: M-89), indications for inpatient admission include hemodynamic instability (NOT MET), respiratory distress (NOT MET), chest pain indicative of serious diagnosis other than coronary artery disease (NOT MET) and angina or myocardial infarction. The reader is referred to guidelines for angina or myocardial infarction, which were not provided. However, given the patient's symptoms and abnormal (and rising) troponin level, there was reasonable suspicion that he was having a non-ST segment elevation myocardial infarction. 
Therefore, an inpatient stay was medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problem-Arrhythmia/Irregular heart problem-Atrial fibrillation
Treatment: Pharmacy/Prescription Drugs-apixaban

The health plan denied the prescription drug formulary exception. 
The reviewer has upheld in whole the health plan's determination. 

The patient has a history of chronic atrial fibrillation treated with apixaban since 2020 for the prevention of stroke. The patient's treating provider has requested prescription benefit exception for continued treatment with apixaban. The patient's prescription plan has denied prescription benefit exception request for apixaban on the grounds the patient did not meet plan criteria documenting treatment failure, intolerance or anticipated adverse effects to the formulary anticoagulants, warfarin and Xarelto. 
Based on the documentation provided for review of this case, there is no indication that the formulary anticoagulant, Xarelto, would be less effective compared to the non-formulary anticoagulant, apixaban. Records do not show treatment failure, intolerance, or provide any indication there would be anticipated adverse effects to the formulary anticoagulants. Based on the 2019 American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Rhythm Society (HRS) focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation, the formulary anticoagulant, Xarelto, would be an appropriate choice of medical therapy to prevent stroke for this patient (1).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned

This male was admitted to this inpatient hospital treatment due to alcohol withdrawal symptoms and medical issues. He had alcohol withdrawal including tremors and a Clinical Institute Withdrawal Assessment Alcohol (CIWA) of 15 which indicated moderate to severe withdrawal. He also had hypoxia and dyspnea with an oxygen (O2) saturation of 86% (percent). He reportedly was found by family on the floor after falling when drinking alcohol. He had elevated blood pressure and had a high D-dimer which was suspicious for possible pulmonary embolism (PE). He had chronic obstructive pulmonary disease (COPD), hypertensions, and diabetes. He reportedly was living with his sister and 10 cats in a flea infested home which was considered uninhabitable. He reportedly was put on a Librium taper of 50 mg (milligrams) every 6 hours for day 1, 50 mg every 8 hours for day 2, and 25 mg every 12 hours for day 3. He was given continuous corticosteroids and bronchodilators, thiamine and folic acid, was put on seizure precautions and had an order for Ativan as needed (prn) and was given intravenous (IV) hydration. He also was put on contact isolation. He still had tremors. He was later discharged. 
 
The US (United States) Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. 

In this case, this patient had several comorbid medical conditions complicating the management of withdrawal and he had active moderate to severe alcohol withdrawal symptoms putting him at high risk for severe, complicated, and life-threatening withdrawal so he required inpatient hospital treatment.

He was considered at risk for more severe withdrawal and worsened medical issues and also was living in an uninhabitable home that was flea infested and required 24-hour inpatient hospital treatment.

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 stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Substance Abuse Inpatient Detoxification Level of Care 
The insurer denied Substance Abuse Inpatient Detoxification Level of Care. The health plan's determination is upheld. 

The patient is an adult male who presented with a request for detoxification treatment. He reported drinking alcohol in large quantity with up to six 24-ounce beers on a daily basis and intermittent use of cocaine using $ (dollars)30 worth three times in the last 30 days. His onset of substance use began in adolescence with continued use. He was medically screened and admitted to inpatient level services for detoxification of alcohol and stabilization and other medical services.
The patient had no history of withdrawal seizures or delirium tremens or prior history of severe withdrawal from alcohol. His self-referral was prompted by his desire to stop using alcohol due to concerns about his use interfering with his life. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 10 with nausea, tremor, anxiety, irritability and insomnia together with normal vital signs.

Substance Abuse Inpatient Detoxification Level of Care is not medically necessary for this patient.
The requested benefit of detoxification treatment and withdrawal management and other medical services could have been safely and effectively provided with lower-level services. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment, and had access to substance use disorder services in the community. Medical necessity is not met in this case for inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature, as well as NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Failure. 
Treatment: Inpatient Admission. 

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

This male patient was hospitalized for heart failure. He presented to the emergency department (ED) from the outpatient (OP) cardiology clinic for management of progressive dyspnea on exertion and leg edema with diuresis. His past medical history (PMH) is pertinent for known heart failure with preserved ejection fraction (HFpEF), hypertension (HTN), diabetes, chronic kidney disease (CKD), cerebral vascular accident (CVA) and peripheral artery disease (PAD). The patient's vital signs were stable. His chest x-ray reported vascular congestion. Brain natriuretic peptide (BNP) was 1852; Troponin was negative; and creatinine (Cr) was 2.2. Treatment included intravenous Bumex, twice daily (BID). 

No, the proposed inpatient admission was not medically necessary. 

Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested acute inpatient hospital stay was medically necessary for this patient. According to the Milliman Care Guidelines (MCG) titled: Heart Failure (ORG: M-190), the inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by chronic kidney disease (CKD) and congestive heart failure (CHF), hypertension requiring inpatient hospitalization, cerebral vascular accident (CVA), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which lower levels of care have failed or are not considered appropriate and that would require acute inpatient management. The care the patient received for mildly decompensated chronic left ventricular (LV) systolic heart failure (HF) is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment is not medically necessary, based on the submitted information and the current published medical literature evidence-based standards. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Diverticulitis. 
Treatment: Inpatient hospital stay. 

The insurer denied the inpatient hospital stay. 
The health plan's determination is upheld. 

The patient is a male with medical history of recurrent diverticulitis. He presented to the emergency department with a day of left lower quadrant abdominal pain, as well as fever and chills. He had presented to an urgent care and been started on Augmentin. Vital signs were notable for pulse rate of 105/minute and elevated blood pressure of 163/105. Physical examination was notable for soft, non-distended abdomen with left lower quadrant tenderness and guarding. Labs showed elevated white blood cell count of 14.1. A Computed tomography scan of the abdomen and pelvis showed moderate edema of the colon centered around the prominent diverticula most consistent with uncomplicated diverticulitis; there was no perforation or abscess. He was treated with intravenous fluids and Zosyn. 

The inpatient hospital admission is not medically necessary. The care provided could have been provided at a lower level of care. In patients with uncomplicated diverticulitis (without complications such as abscess or perforation), a lower level of care is the standard of care. The safety and efficacy of this in acute uncomplicated diverticulitis has been demonstrated. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics. A systematic review of the literature underscored this. 

In this case, there was no protracted fever or hypotension to suggest that intravenous antibiotics in the hospital were ineffective. There had been no definitive evidence of abscess on imaging. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. The patient improved on intravenous antibiotic therapy, and was appropriately discharged on antibiotic therapy. For these reasons, the inpatient level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic obstructive pulmonary disease, sciatica, severe arthritis, diabetes with vascular complications. 

Treatment: Personal care services (PCS) of 24 hours per day, 7 days per week (live-in). 

The insurer denied coverage for personal care services (PCS) of 24 hours per day, 7 days per week (live-in). 

The denial is modified. 

This is a patient with multiple medical problems including paraplegia, chronic obstructive kidney disease (COPD), kidney disease, and coronary artery disease.  She lives alone in a 1-bedroom apartment.  The patient currently has Personal Care Services (PCS); 10 hours/day, 7 days/week for a total of 70 hours.  Under review is the request for increase Personal Care Services (PCS); 24 hours/day, 7 days/week (live-in). 

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance for activities of daily living that include bathing, dressing and toilet use.  She is incontinent of bowel and bladder.  Bed mobility is independent; however, she is non-ambulatory and wheelchair dependent.   Cognitive status is intact, with good short- and long-term memory.  The office visit notes from the patient's treating physician were also received, documenting her functional decline.  While cognitively intact, the patient's functional decline supports an increase in Personal Care Services.  This physician recommends increasing PCS to 12 hours/day, 7 days/week for a total of 84 hours in order to allow the patient to continue living safely at home. 

The healthcare did not plan acted reasonably, with sound medical judgment or in the best interest of the patient. 

From a physical medicine and rehabilitation perspective, the requested increased Personal Care Services (PCS); 24 hours/day, 7 days/week (live-in) is not considered medically necessary for this patient. 

From a physical medicine and rehabilitation perspective, increasing Personal Care Services (PCS); 12 hours/day, 7 days/week for a total of 84 hours is considered medically necessary for this patient. 

The insurer's denial of coverage for Personal Care Services of 24 hours per day, 7 days per week (live-in) is modified. Medical Necessity is substantiated for 12 hours/day, 7 days a week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic brain injury, Alzheimer's dementia, depression and seizure disorder.

Treatment Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift).

The insurer denied coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift).

The denial is overturned.

This is a with multiple medical problems including traumatic brain injury, Alzheimer's dementia, depression and seizure disorder.  She requires a hospital bed and lives with her spouse in a 2-bedroom apartment.  Due to space requirements, the spouse sleeps in the separate bedroom.  The patient had been receiving personal care aide (PCA) services 12 hours/day, 7 days/week for a total of 84 hours.  After the spouse requested increased PCA services (24 hour-split shift), the insurer approved an increase to 24 hours/day via a live-in PCA.  However, due to the lack of accommodation for a live-in PCA, the patient continues to receive the PCA services 12 hours/day, 84 hours/week.  Under review is the request for increase Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift).

According to the Uniform Assessment System (UAS) report, the patient is totally dependent for activities of daily living including bathing, dressing, personal hygiene and toilet transfers/use.  She requires maximal assistance for bed mobility and extensive assistance for eating.  The patient is essentially bed confined and unable to ambulate.  Her cognitive status is described as "severely impaired."   The patient requires total care, is (hospital) bed dependent and requires 24-hour supervision.  She requires frequent re-positioning, skin checks and changing due to bowel/bladder incontinence.  The patient's requirement for uninterrupted care (day and evening) renders the approved 24 hours/day via a live-in PCA insufficient.  This physician agrees that the combination of factors (cognitive impairment, total functional dependence and need for uninterrupted care/supervision) support the requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) as medically necessary and allows the patient to continue living safely in a home setting.   

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested increased Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is considered medically necessary for this patient.  

The insurer's denial of coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoarthritis.
Treatment; Consumer Directed Personal Assistant Services (CDPAS): 84 Hours per Week.
The insurer denied Consumer Directed Personal Assistant Services (CDPAS): 84 Hours per Week 
The denial is overturned

The patient is a male with past medical history of hyperlipidemia, hypertension, gastroesophageal reflux disease (GERD), diabetes with diabetic neuropathy, urinary frequency and urgency, lumbar radiculopathy, coronary artery disease, lumbar disc disease, osteoarthritis, depression, insomnia, cognitive impairment, urinary incontinence, and asthma. There was a request to increase CDPAS services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of shopping and dressing lower body. The patient was assessed at extensive assistance with tasks of stairs, transportation, bathing, dressing upper body, walking, and locomotion while limited assistance with tasks of managing finances, managing medication, phone use, personal hygiene, transfer toilet, and toilet use. With tasks of bed mobility and eating the patient was assessed at independent and notes from the assessment stated the patient was weaker following his recent fall, had a decline in activities of daily living (ADL) status over the last 90 days, and had deterioration of overall self-sufficiency in the last 90 days.

Consumer Directed Personal Assistant Services (CDPAS): 84 Hours per Week is medically necessary for this patient.
The patient has documented worsening cognitive and functional status. The patient requires at least limited assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) except for bed mobility and eating. The patient's medical providers have documented medical necessity of increased CDPAS hours. The plan assumed, incorrectly, that the patient has informal help outside of the currently assigned CDPAS hours. The daughter is not able to provide informal help for all of the hours outside of CDPAS help. The patient has unscheduled and unpredictable care needs and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 84 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 his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spondylosis. 
Treatment: Outpatient procedure codes 64483 x 1 and 64494 x 1, (ESI) epidural steroid injection. 

The insurer denied coverage for outpatient procedure codes 64483 x 1 and 64494 x 1, ESI. 

The denial is upheld. 

This patient is a male with a history of low back pain. The patient had an ESI. He reported an initial pain relief of 80% (percent). However, the pain level was at an 8 out of 10. The physician recommended an additional ESI to treat pain. 

The standard definition of a successful epidural steroid injection is at least 50% pain relief for 2 weeks following the injection. (1,2) This was not achieved in this case and therefore a second injection is not supported. It is not medically reasonable or necessary. 

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

The insurer's denial of coverage for the outpatient procedure codes 64483 x 1 and 64494 x 1, epidural steroid injections (ESI) is upheld. Medical necessity is not substantiated.