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

Diagnosis: Osteoarthritis.
Treatment: Home care/personal care level 2 personal care services, 24 hours per day (live-in).
The insurer denied coverage for home care/personal care level 2 personal care services, 24 hours per day (live-in).
The denial is overturned.

This case involves an elderly patient who has been diagnosed with hypertension, hyperlipidemia, hypothyroidism, osteoarthritis, macular degeneration, and cervicalgia.  Per assessment, he previously had 56 hours of personal assistance services (PAS).  The documentation indicated the patient's condition has deteriorated significantly over the past few years due to advancing osteoarthritis.  Per physician's documentation it is noted he can still walk very slowly with a walker; however, it is very difficult due to shoulder pain which has worsened in addition to arthritis to the knee.  He can no longer get out of a chair to stand by himself.  The patient has also developed urinary dribbling necessitating a diaper.  He can no longer pull up a diaper by himself.  He also has macular degeneration which has caused blindness in 1 eye.  It has been recommended he receive care 24 hours a day.

This patient has a history of hypertension, dyslipidemia, hypothyroid state, generalized degenerative joint disease which is causing progressive impairment in his mobility and macular degeneration which is causing significant vision loss. The records reviewed indicate that he is no longer safe to be left alone for any length of time. He is at high risk for falls and hospitalizations and will likely not be able to call for help due to decreased mobility and vision. He lives alone with no safety net. Increasing his PAS hours to 24 hours is medically necessary.

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

Based on the above, the medical necessity for the home care/personal care level 2 personal care services, 24 hours per day (live-in) is substantiated. The insurer's denial is overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lymphadenopathy
Treatment: PET Scan (code 78815)

The insurer denied the PET Scan (code 78815).
The denial is upheld.

The patient is a male treated with liver transplant for primary sclerosing cholangitis. He had enlarged lymph nodes on CT (computed tomography) scan.  PET/CT (positron emission tomography/computed tomography) was performed.

No, the health plan should not cover the PET (positron emission tomography) Scan (code 78815).

No, the requested health service is not more beneficial.
The NCCN (National Comprehensive Cancer Network) states that either PET/CT (positron emission tomography/computed tomography) or CT (computed tomography) scans can be used for evaluation of PTLD (post-transplant lymphoproliferative disease).  Given that this individual had an abnormal CT (computed tomography), the next step in management would be to obtain a biopsy to establish a diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lymphadenopathy
Treatment: PET Scan (code 78815)

The insurer denied the PET Scan (code 78815).
The denial is upheld.

The patient is a male. He had a liver transplant for primary sclerosing cholangitis. He developed abdominal bulging in the area of his surgical scar. A CT (computed tomography) of the abdomen showed scattered lymphadenopathy. He had no B-symptoms and LDH (lactate dehydrogenase) was normal.

A PET/CT (positron emission tomography/computed tomography) was then performed to evaluate suspected post-transplant lymphoproliferative disorder.

Coverage for the PET/CT (positron emission tomography/computed tomography) was denied by the health plan as they do not cover PET/CT (positron emission tomography/computed tomography) without a diagnosis of cancer.

No, the health plan should not cover the PET (positron emission tomography) Scan (code 78815)
The patient developed diffuse adenopathy after liver transplantation on CT (computed tomography) scan. There was a suspicion of post-transplant lymphoproliferative disorder (PTLD). PTLD (post-transplant lymphoproliferative disorder) is a well-known, life-threatening complication after organ transplantation, predominantly following solid organ transplantation and hematopoietic stem cell transplantation. The majority of the cases of PTLD (post-transplant lymphoproliferative disorder) are associated with Epstein-Barr virus (EBV), and it occurs within the first posttransplant year (1).

The diagnosis of PTLD (post-transplant lymphoproliferative disorder) requires a tissue biopsy. PET/CTs (positron emission tomography/computed tomography) are not recommended prior to making a diagnosis (2).

The review of PET/CT (positron emission tomography/computed tomography) in the management of PTLD (post-transplant lymphoproliferative disorder) provided by the provider concludes, "Although data in the literature are relatively scarce and little prospective data exist, it appears that FDG-PET/CT [fludeoxyglucose positron emission tomography/computed tomography] may have a role in the work-up, staging and therapy response assessment of patients with PTLD [post-transplant lymphoproliferative disorder]...Nonetheless, the true impact of PET [positron emission tomography] on the management and outcome of patient's with PTLD [post-transplant lymphoproliferative disorder] should be determined prospectively in future trials." (3)

The testing is of unproven benefit, and the plan should not cover services that are of unproven efficacy.

No, the requested health service is not more beneficial than any standard treatment for the insured's condition or disease.
The recommended evaluation for this insured was excisional biopsy of a lymph node.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lymphadenopathy
Treatment: PET Scan (code 78815)

The insurer denied the PET Scan (code 78815).
The denial is upheld.

The patient is a male. The patient in this case underwent liver transplant and was subsequently found to have widespread lymphadenopathy on imaging.  He was suspected of having post-transplant lymphoproliferative disorder (PTLD). PET/CT (positron emission tomography/computed tomography) was performed and revealed that this lymphadenopathy was associated with significantly increased FDG (Fludeoxyglucose) uptake.  Biopsy was recommended.

No, the health plan should not cover the PET (positron emission tomography) Scan (code 78815).
This patient was found to have lymphadenopathy but did not have a diagnosis of cancer.  While it is noted that he was suspected to have PTLD (post-transplant lymphoproliferative disease), that diagnosis had not been established, and there are definitely other potential causes of lymphadenopathy in patients who have undergone liver transplant.  PET/CT (positron emission tomography/computed tomography) is not a standard test in the evaluation of lymphadenopathy and has not been shown to improve health outcomes in that setting.  The PET/CT (positron emission tomography/computed tomography) done in this case should not have been covered and was not more beneficial than the next standard test, which was biopsy.  While it is noted that PET/CT (positron emission tomography/computed tomography) is an effective test for patients diagnosed with PTLD (post-transplant lymphoproliferative disease), this patient had not yet been diagnosed with PTLD (post-transplant lymphoproliferative disease).

No, the PET (positron emission tomography) Scan (code 78815) is not more beneficial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esophageal ulceration
Treatment: Endoscopy (CPT 43239)
The insurer denied the Endoscopy (CPT 43239).
The denial is upheld.

The patient is a female for whom the provider undertook an Endoscopy (43239). The patient had undergone a previous recent endoscopy. The patient then underwent this repeat endoscopy for the diagnosis of a prior esophageal ulceration.

No, the Endoscopy (43239) was not medically necessary.

There is no cogent medical reason or medical literature to support a repeat endoscopy for the findings of an esophageal ulceration. While this is a standard in the management of gastric ulcers, it is not for esophageal ulcers. Treatment is the appropriate step, not a repeat endoscopy at any point for the purposes of ensuring healing.

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: Rule out acute coronary syndrome
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.
The denial is upheld. 

This female patient has a history of diabetes, hypertension, hyperlipidemia, constipation, chronic incontinence, gastroesophageal reflux disease (GERD) and chronic lower back pain.

Using the HEART (history, ECG abnormalities, age, risk factors, and troponin) score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (4,5). They found no significant difference in outcome at 30 days between the two groups. Fernanda Bellolio, et al noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30 day myocardial infarction rates as those admitted to the hospital (5). Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.

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

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

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

The patient is a female with history of speech delay. She was evaluated due to cough and nasal congestion for four days and breathing difficulty for one day. She was evaluated at her primary physician's prior to admission and started on albuterol nebulizers with no improvement.

In the ED (emergency department), the patient's vital signs were T (temperature) 102.6, P (pulse) 168, BP (blood pressure) 119/51, pulse oximetry 97% on room air. She was noted to have retractions and increased work of breathing. VBG (venous blood gas), CBC (complete blood count), BMP (basic metabolic panel), CXR (chest x-ray) and urinalysis were unremarkable. Blood cultures were drawn. Viral testing was positive for RSV (respiratory syncytial virus).

The patient was given a normal saline bolus and started on BiPAP (bi-level positive airway pressure). Upon admission, vital signs were P (pulse) 115, R (respiration rate) 33, pulse oximetry 96% on room air. She was noted to have tachypnea but no other increased work of breathing. Her perfusion was appropriate. She was started on maintenance IVF (intravenous fluid) and continued on BiPAP (bi-level positive airway pressure). Later that day, she was transitioned to HFNC (High-Flow Nasal Cannula). She was on 6 LPM (liters per minute) HFNC (High-Flow Nasal Cannula) at FiO2 (fractional inspired oxygen concentration) .35. She was transferred to the floor and discharged later that day.

No, the Inpatient admission was not medically necessary.
The child was admitted for bronchiolitis. There is no documentation of hypoxia, inadequate ventilation, inability to maintain oral hydration, lethargy, or any other finding that required an acute inpatient level of care. At the time of admission, the child had minimally increased work of breathing, adequate perfusion, and was appropriately maintaining oxygen saturations. The interventions provided, which included suctioning, respiratory support, and hydration, could have safely been provided at a lower level of care. The acute inpatient hospital stay was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The child's condition could have been safely treated at a lower level of care. The plan was reasonable and appropriate with the denial of the acute inpatient hospital stay based on the records provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Complex regional pain syndrome of right upper extremity and hand

Treatment: 10 additional physical therapy (97164) visits

The insurer denied coverage for 10 additional physical therapy (97164) visits.

The denial is upheld. 

This female patient has a history of asthma, diabetes mellitus, pancreatitis, sleep apnea, appendectomy, cholecystectomy, herniated discs and complex regional pain syndrome of her right upper extremity and hand.

The physical therapy treatment notes provide insufficient clinical information to support the medical necessity of continuing physical therapy indefinitely.  There is only 1 physical therapy treatment note enclosed for review.  Treatment was "Active release technique performed to the cervical spine, thoracic spine, right shoulder and wrists in the supine position."  However, the clinical efficacy of weekly active release technique for the diagnosis of right upper extremity complex regional pain syndrome is not supported.  In addition, The patient should be independent with a home exercise program after months (and years) of treatment.  Continued weekly physical therapy in this particular case, is no more than maintenance treatment and is not medically necessary.   

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

The carrier's denial of coverage for 10 additional physical therapy (97164) visits is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This patient presented to the hospital complaining of palpitations and fatigue. She reported symptoms of an upper respiratory infection and contact with co-workers that tested positive for COVID-19 (2019 Coronavirus) infection.  Despite several negative COVID tests, she noted persistent fatigue, decreased oral intake and palpitations.  On arrival to the hospital, she was noted to be tachycardic with a pulse of 123 beats per minute (bpm).  Blood pressure was normal 133/74.  Physical examination revealed no significant abnormality. 12 lead electrocardiogram (ECG) revealed sinus tachycardia.  Serum blood testing revealed hypokalemia with a potassium of 3.0 milliequivalents per liter (mEq/L).  Thyroid stimulating hormone (TSH) and D-dimer levels were within the normal range.  She was treated with intravenous (IV) fluid and was admitted to the hospital.  Echocardiogram revealed a normal left ventricular ejection fraction (LVEF) with no significant valvular abnormalities.  She was ultimately discharged home after treatment with IV fluids. 

The insurance plan acted reasonably, with sound medical judgement and in the best interest of the patient. This patient had a complete work up including ECG, echocardiography, thyroid function, and d-dimer that were all unrevealing. She was treated with intravenous fluids (IVF) despite the fact that her blood urea nitrogen and creatinine (BUN/CR) ratio was within the normal range and physical examination did not reveal signs of dehydration.  History was significant for an upper respiratory tract infection.  Ultimately her heart rate returned to the normal range and the patient was discharged with general medical follow up. 

Inpatient admission was not necessary for this otherwise healthy patient without significant past medical history.  Her heart rate normalized without treatment and electrolyte repletion does not require inpatient care. There were no significant abnormal findings on physical examination or ECG to warrant acute inpatient hospital admission.  Most patients with palpitations can be evaluated in the outpatient setting. (Reference 1-2) 

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

Diagnosis: Coronary artery disease, benign prostatic hypertrophy, hypertension, arthritis, narcolepsy, neuropathy, spinal stenosis and cervical spine fracture
Treatment: Increased home care/personal care Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in)  

The insurer denied coverage for home care/personal care Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in) as not medically necessary.
The denial is overturned.

The patient has coronary artery disease, benign prostatic hypertrophy, hypertension, arthritis, narcolepsy, neuropathy, spinal stenosis and cervical spine fracture.  

A Uniform Assessment System (UAS) showed that the patient has mild memory impairment requiring extensive assistance or is dependent for instrumental activities of daily living (IADL).  He is independent for bed mobility; he needs limited assistance for hygiene, upper body dressing, walking, locomotion and toilet transfer. The patient requires extensive assistance for toilet use and lower body dressing. He self-catheterizes and has occasional bowel incontinence. The patient's doctor notes that the patient needs assistance with all ADLs (activities of daily living) and needs 24-hour assistance.  

The patient was previously approved for 56 hours per week of services. An increase to 24 hours per day (live-in) was requested. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

(a) Definitions and scope of services.
(1) Personal care services mean assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The patient needs assistance with essentially all ADLs. He self-catheterizes and needs to get to the bathroom and do this twice during the night. He cannot do this by himself. If not provided with personal care services, he is at increased risk of a fall and has already sustained a cervical fracture. In this case there are unscheduled needs including at night.

The documentation supports unscheduled nighttime needs and the need for assistance including with toileting and the request is approved. 

Based on the above, the medical necessity for the home care/personal care Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery calcium (CAC) over1000
Treatment: Left Heart Catheterization
The insurer denied the Left Heart Catheterization.
The denial is overturned.

The patient is a male who was screened with a positive calcium score of greater than 1000. This was followed with a stress perfusion scan that showed a reversible defect on the apical and anterior walls. Left heart cardiac catheterization was performed. It revealed multi-vessel disease with the left main (LM) 30%; left anterior descending (LAD) 50%; right coronary artery (RCA) 10; circumflex (CIRC) 20%, a pressure wire was passed in the left anterior descending, and instantaneous wave-free ratio (IFR) was 0.92. Medical treatment was recommended.

The appeal is to overturn the denial of the cardiac catheterization.

Yes, the proposed cardiac catheterization was medically necessary.
A Coronary Calcium score was performed with a value of over 1000. This was followed by a stress test that revealed reversible disease in two areas. The treating physicians then performed a radial artery cardiac catheterization with evidence of moderate multi-vessel disease, and borderline positive instantaneous wave-free ratio (IFR) in the left anterior descending (LAD). Medical therapy was recommended.

A calcium score over 1000 is associated with a very high risk of cardiovascular events, over 37% in ten years. It was followed by a non-invasive test that showed evidence of reversible ischemia. At this point it is reasonable and consistent with community practice to proceed with a cardiac catheterization. In this case moderate disease was seen, instantaneous wave-free ratio (IFR) was measured, and appropriate recommendation of aggressive risk factor modification was made.

Another non-invasive study, including a computed tomography (CT) fractional flow reserve (FFR) would not be useful due to high calcium burden. Nor would any other non-invasive test be able to make a cardiac catheterization not medically necessary in this case.

While medical therapy is appropriate for single vessel disease, one could not be certain of that without performing an invasive cardiac catheterization.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appropriate testing determination based on sound medical judgement is in best of interests of patient. In this case, with the results of calcium scoring, providers may compare a patients coronary artery calcium (CAC) score to patients of similar age, (4.3 percent).  The patient had an initial coronary artery calcium (CAC) score 1000 . Over a mean follow-up of more than 12 years, patients with an initial coronary artery calcium (CAC) score of 1000 had significantly higher risk of developing cardiovascular disease (CVD). Standard and aggressive medical treatment alone had an insignificant effect on outcome, so with a positive imaging study, one must stratify with an angiography.