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

Diagnosis: Coronary artery disease, congestive heart failure, dizziness, exertional dyspnea and fatigue
Treatment: Increase Personal Care Aide (PCA) Level 2: 10 Hours Per Day 7 Days Per Week For A Total Of 70 Hours Per Week
The insurer denied the Increase Personal Care Aide (PCA) Level 2: 10 Hours Per Day 7 Days Per Week For A Total Of 70 Hours Per Week.
The denial is overturned.

The patient is a female with a history of coronary artery disease, congestive heart failure, dizziness, exertional dyspnea and fatigue. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 70 hours per week Personal Assistance Services to offer increased ADL support.

Yes, the Increase Personal Care Aide (PCA) Level 2: 10 Hours Per Day 7 Days Per Week For A Total Of 70 Hours Per Week is medically necessary.

This is a female with a history of coronary artery disease, congestive heart failure, dizziness, exertional dyspnea and fatigue. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). A recent clinic visit with her provider indicates that due to the patient's worsening dizziness, neck, low back, knee pain and generalized weakness, the patient is completely homebound and requires assistance for completion of all activities of daily living. Hence, the currently approved plan of 56 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 70 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

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

The patient is a man with a history of seizures who presented to the emergency department after experiencing multiple seizures at home. According to emergency medical services, the seizures were witnessed by family members and there was no trauma associated with them. He was in a post-ictical state when he arrived in the emergency department. He stated he was feeling well prior to his seizures that day. Vital signs showed blood pressure 126/75, temperature 98 Fahrenheit, heart rate 82, respiratory rate 18, and oxygen saturation 100%. On physical exam, heart was regular, breath sounds were normal and the abdomen was soft. There were no neurologic deficits. He was given 1 g (gram) of intravenous (IV) Keppra. The emergency department attending stated that he recommended admission but the patient initially declined. Chest x-ray was negative for pneumonia. Labs showed creatinine 1.1, blood urea nitrogen (BUN) 13.0, white blood cell (WBC) 6.2, hemoglobin 15.0, and platelets 267. The patient was admitted for seizures thought to be secondary to non-adherence to neuroleptics. 

The Inpatient Hospital Admission not medically necessary for this patient.
The reason is that the patient presented with a breakthrough seizure in the setting of medication non-adherence but did not have an acute cause for this seizure beyond medication on adherence. Imaging was negative for infection, there was no evidence of meningitis, there was no evidence of acute toxic ingestion, and he was hemodynamically stable. Because of the absence of active seizure activity, or high suspicion for active seizure activity, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis; Clostridium difficile toxin infection.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld. 

This female patient has a medical history of sickle cell trait and presented to the Emergency Department (ED) with complaints of diarrhea. The patient had a history of gastric sleeve surgery and a recent pyelonephritis, and was treated with antibiotics. The patient presented to the ED with abdominal pain and diarrhea. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The patient's computed tomography (CT) scan revealed portal vein thrombosis. The patient was diagnosed with a Clostridium difficile (C. diff) toxin infection. The patient was started on intravenous (IV) Flagyl and then treated with oral vancomycin. The patient was given Lovenox and then oral anticoagulation. The patient was discharged on oral vancomycin and Apixaban.

As per MCG guidelines, clinical indications for admission for gastroenteritis (M-170) include a suspected severe infection, severe abdominal pain, peritoneal signs, toxic mega colon, hemodynamic instability, severe vomiting, severe dehydration, or a severe electrolyte abnormality. In this case, the patient did not have these clinical conditions.

Based on the review of the medical record, this patient had enteritis from a Clostridium difficile infection. The patient required stool testing and then could have been treated as an outpatient setting with oral vancomycin. The patient also received anticoagulation but could have been treated with the Apixaban as an outpatient. The patient had some blood in the stool but was not actively bleeding. The patient did not meet the MCG criteria for inpatient admission for gastroenteritis. The patient could have been managed with observation status. Inpatient hospital admission is not considered medically necessary for this patient.

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

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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Prolia. 
The health plan's determination is upheld. 

The patient is a female with diabetes, hypertension, peripheral arterial disease and end-stage renal disease status post renal transplant x3. She has a history of chronic kidney disease with a creatinine of 1.5. A recent bone density study demonstrated a T score of -1.7 in the femur and 0.3 in the spine. The provider stated that the patient cannot take Fosamax. Prolia was prescribed for osteopenia. The subject under review is the medical necessity for Prolia. 

The health plan's determination is upheld. 

The use of Prolia is not medically necessary for this patient. The standard of care for treatment of osteopenia, including in patients with renal transplants, does not include Prolia. The patient has not failed or been intolerant to bisphosphonates and vitamin D or vitamin D analogs for the treatment of osteopenia. Bisphosphonates are not contraindicated in patients with renal transplants. In addition, the patient does not have a history of a fragility fracture and does not have osteoporosis as there is no T score of -2.5 or lower. Prolia is not approved for the treatment of osteopenia. In summary, Prolia is not medically necessary in this case based on the standard of care for treatment of osteopenia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective automatic implantable cardioverter
defibrillator. 
Treatment: Inpatient admission. 

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

The patient is a male. He had a past medical history significant for hypertension, dyslipidemia, non-obstructive coronary artery disease (CAD), severe aortic stenosis status post (s/p) transcatheter aortic valve replacement (TAVR), left bundle branch block, non-ischemic cardiomyopathy, systolic congestive heart failure (CHF) with ejection fraction (EF) of 30% and coronavirus disease (COVID-19) infection.  

The patient presented for elective automatic implantable cardioverter defibrillator (AICD)/bi-ventricular pacemaker implantation. The patient was hemodynamically stable. The patient underwent the procedure with no documented complications.  He was admitted for post-operative monitoring and care. The chest x-ray post procedure revealed normal placement of the leads and no evidence of pneumothorax. He was discharged home the next day with a plan for outpatient follow-up. 

No, the proposed treatment, Inpatient Admission was not medically necessary. 

This patient with known non-ischemic cardiomyopathy, presented for an elective implantation of a bi-ventricular pacemaker/defibrillator. The patient underwent this procedure with no complications. There was no evidence of pneumothorax, bleeding, lead perforation, pericardial tamponade, acute MI, hemodynamic instability, etc. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied Guardant 360. 
The denial is upheld in whole. 

The patient is a female with stage IV adenocarcinoma of the lung. The disease is epidermal growth factor receptor (EGFR) mutated, anaplastic lymphoma kinase (ALK)-, proto-oncogene B-Raf (BRAF)-, programmed death ligand one (PD-L1) unknown, neurotrophic tyrosine receptor kinase (NTRK)-, c-ros oncogene 1 (ROS1)-, and the patient has received erlotinib, osimertinib, and carboplatin plus pemetrexed and bevacizumab. The patient has progressed. The Guardant360 assay was ordered and is under review for medical necessity.

The health plan's determination is upheld in whole.

The Guardant 360 was not medically necessary for this patient. The use of next generation sequencing gene panels to guide the treatment of patients with lung cancer (for which biomarkers have already been assessed) has not been demonstrated to be of benefit. The assay is question is Food and Drug Administration (FDA) approved. Several ongoing trials (e.g., the National Cancer Institute [NCI] Molecular Analysis for Therapy Choice [MATCH] and the American Society of Clinical Oncology [ASCO] Targeted Agent and Profiling Utilization Registry [TAPUR] trails) are using next-generation sequencing of multiple genes (gene panel tests) to identify molecular abnormalities in the tumors of patients with refractory cancers that may potentially match molecularly targeted therapies that are either in clinical trials or approved for treatment of other cancer types (National Clinical Trial [NCT] 02465060 and NCT02693535).

An important point is that simply having a potentially targetable mutation does not guarantee that the patient will benefit from a therapy that presumably targets that mutation. Another potential issue is if targeted testing identifies a potentially actionable genetic abnormality for which a molecularly targeted treatment is available but not yet approved.

Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Guardant360 assay in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged. For these reasons, the use of this assay in this scenario does not meet criteria for a medically necessary service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis, CVA and hypertension
Treatment: Increase in PCA services to 84 hours per week
The insurer denied the Increase in PCA services to 84 hours per week.
The denial is overturned.

The patient is a male with a history of rheumatoid arthritis, CVA (cerebrovascular accident) and hypertension. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.

This is a male with a history of rheumatoid arthritis, CVA (cerebrovascular accident) and hypertension. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation of the patient's functionality and ability to perform ADLs (activities of daily living) was completed. It was revealed that due to the patient's progressively worsening weakness and functional status, the currently approved plan of 35 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She was 21-weeks pregnant at the time of admission. Her medical history included gallstones. She presented to an emergency room with dizziness, nausea, vomiting, and right upper quadrant abdominal pain. Her vitals were temperature 36.1, pulse 88, blood pressure 102/82, respirations 20, and saturations 100%. Physical examination demonstrated tenderness to palpation of the right upper quadrant of the abdomen. Serum laboratories demonstrated a white blood cell count of 10.31. Abdominal ultrasound demonstrated gallstones. 

The patient was admitted at an acute inpatient level of care with a diagnosis of acute cholecystitis. The patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated. Pre- and post-operative fetal evaluations were unremarkable. 

Having returned to her baseline health and function, she was discharged home in good and stable condition without outpatient surgical and obstetric follow-ups.

No, the proposed treatment for admission at an acute inpatient level of care was not medically necessary.

Based on the provided medical documentation and in accordance with national guidelines, for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated at an outpatient or observational level of care.


According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES]. 

Insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission at an acute inpatient level of care. In addition, fetal evaluations can be been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic pain and Fibroids. 

Treatment: Code 58572: Laparoscopy, Surgical with Total Hysterectomy, for uterus greater than 250 grams performed for treatment of pelvic pain.

The insurer denied coverage for code 58572: Laparoscopy, Surgical with Total Hysterectomy, for uterus greater than 250 grams performed for treatment of pelvic pain.

The denial is upheld. 

This is a female patient with a history of menorrhagia and fibroids. An ultrasound showed two exophytic fibroids: one fibroid measured 2-2.5 centimeters (cm) in size and the second fibroid measured 4 cm in size. The patient's endometrial biopsy showed normal secretory endometrium. The provider's plan was to proceed with a hysterectomy.

Based on the review of the medical record, it is not clear why this patient needs a hysterectomy. The only abnormal findings are 2 exophytic myomas relatively small in size. As per literature review, fibroids are very common and rarely cause pain. It is very unlikely that a 4 cm fibroid could be the reason for this patient's pain. Note that the patient's pain could have many different etiologies and it is not clear from the progress notes that other etiologies for the pain have been ruled out. Thus, a hysterectomy is not indicated at this time.
 
The standard of care according to UpToDate would be the following: medical treatment to shrink the fibroids and if the pain improves then the fibroids will be to blame and surgical management may be necessary. As of now there is no indication for hysterectomy in this patient. Also, exophytic fibroids are very easy to remove laparoscopically without the need for removing the uterus.

The coverage of code 58572: Laparoscopy, Surgical with Total Hysterectomy, for uterus greater than 250 grams performed for treatment of pelvic pain is not considered medically necessary for this patient at this time. 

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

Based on the above, the medical necessity for code 58572: Laparoscopy, Surgical with Total Hysterectomy, for uterus greater than 250 grams performed for treatment of pelvic pain is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: 7 additional units of a continuous positive airway pressure (CPAP) device and humidifier.

The insurer denied coverage for 7 additional units of a continuous positive airway pressure (CPAP) device and humidifier.

The denial is overturned. 

This is a male patient who was diagnosed with obstructive sleep apnea (OSA). The patient was prescribed a continuous positive airway pressure (CPAP) machine. 

The patient has clinical signs of OSA and a home sleep study also confirmed the diagnosis. The patient's insurance company had denied further CPAP due to non-compliance by the patient. The patient had some initial issues with CPAP as documented on previous sleep reports: the patient had used the machine for 67 out of 90 days; 74 % of the 67 days, the usage for greater (>) or equal to 4 hours was 17 days or 19%; Less than 4 hours was 50 days. This was less than the requirement of usage for 4 hours or more in 70 % of the nights.

This patient supplied a more recent report of usage. During this period, the patient used the machine 23 out of 30 days. Due to his occupation, he sleeps at work when he is on call and does not carry his sleep machine to work. During this period the average time on the machine was 6 hours and 51 minutes per day.

The patient reports dramatic improvement in his clinical symptoms since use of his CPAP machine. In addition, his apnea-hypopnea index (AHI) has also come down to under 1 with regular use of CPAP. Given that the patient has an established diagnosis of OSA and after initial trouble with the machine has now gotten used to it and using it as it is supposed to be used, there is no justification to stop his CPAP therapy at this time.

The health plan did not act reasonably in the best interest of the patient.

Based on the above, the medical necessity for 7 additional units of a CPAP device and humidifier is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient underwent gastric band surgery in the past. She developed worsening epigastric abdominal pain, nausea, vomiting, and decreased oral intake over a period of 2-3 weeks. She presented to the emergency department (ED) for evaluation. Vital signs in the ED and preoperatively were normal. A computed tomography (CT) scan showed the gastric band and wall thickening of the distal esophagus and gastroesophageal junction. A surgical consultation was obtained. The records indicate that the band had been previously decompressed of its fluid. The patient was treated with intravenous (IV) fluid, nothing by mouth (NPO) status, pain medications and antiemetics. The patient was receiving IV fluid and antiemetics as ongoing, non-operative therapy for band slippage. She was reported to be feeling better. She was maintained with nothing to eat.
The patient underwent laparoscopic removal of the adjustable gastric band. The operative dictation describes an uncomplicated intraoperative course that included lysis of adhesions, removal of the gastric band and subcutaneous port. The patient was monitored on the surgical floor following surgery. She complained of moderate abdominal pain, but denied nausea or vomiting. The medical and nursing records document clinical stability following the operation. The nausea and vomiting resolved. She was started on a diet and was considered to be stable for discharge home. At issue is the medical necessity of an inpatient stay.

Inpatient stay from was not medically necessary in this case based on the medical record. The clinical requirements of IV fluid, anti-emetics, narcotic therapy, and surgical removal of the lap band device could have been reasonably delivered at a lower level of care.
The medical records support that this patient required pre- and post-surgical parenteral pain medication, anti-nausea medications, and clinical monitoring. While gastric banding and gastric band removal can frequently be performed as an outpatient procedure, there are clinical conditions for which hospital confinement is required. Such conditions include parenteral pain management, supplemental oxygen delivery and oxygen saturation monitoring for the patient with obstructive sleep apnea, and intolerance of adequate oral intake requiring IV fluid supplementation. Complications of surgery may also require hospital confinement. In this case, the documentation supports that the patient was hemodynamically stable at the time of ED presentation. She underwent an uncomplicated operation and was able to be advanced to a diet on the day following surgery.
This patient was afebrile, was clinically stable prior to surgery and in the post-surgical period, and was able to start a diet on the first post surgical day. The records indicate that there was a delay in performance of surgery. It was clinically appropriate for this patient to be maintained at a lower level of care per generally accepted standards of medical care.