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

Central Nervous System/Neuromuscular Disorder
Home Health Care

This is a patient with a past medical history of osteoarthritis, dementia, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia and bowel and bladder incontinence who had been approved for 35 hours/week of personal care assistant (PCA) services. The patient lives with her grandson and he gets home at 7:00 PM on weekdays and is able to perform informal help. The patient had a fall while going to the bathroom requiring a visit to the emergency room. Per family the patient has had a change in her activities of daily living (ADLs) and instrumental activities of daily living (IADLs) since the fall. The patient had an assessment tool performed indicating total assistance needed for meal preparation, ordinary housework and shopping. The patient was assessed to need maximal assistance with tasks of stairs and transportation. She needs assistance with activities of managing finances, bathing, personal hygiene, dressing upper/lower extremity, walking, locomotion and transfer toilet. The patient was assessed to need limited assistance with tasks of managing medication, phone use and toilet use and was independent with bed mobility and eating. The patient scored 14/30 on a Mini-Mental State Examination (MMSE) at a latest assessment. At issue is the medical necessity of an increase in PCA hours to 55 hours/week.
The health plan's determination is overturned. The requested increase in personal care hours from 35 hours per week to 55 hours per week is medically necessary. The patient's assessment tool indicated the patient needs help with ADLs and IADLs except for bed mobility and eating. The patient does not have an informal helper for 19 hours per day due to her grandson working. Her grandson needs to work and in order for patient to remain independent in her home, she would require 55 hours/week of PCA service. The additional requested PCA services above the previous 35 hours/week are not just for oversight and supervision and the patient had unscheduled needs during the times that she is alone.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia 
Treatment: Inpatient stay 

Summary:
The patient is a female with a past medical history significant for HTN (hypertension), dyslipidemia, type I diabetes mellitus. She presented for an episode of hypoglycemia and altered mental status. The patient reported not eating the night prior. She was given two doses of glucose by the husband prior to presentation. Repeat blood glucose was 169 mg/dL. 

The patient presented for evaluation of hypoglycemia due to not eating in the setting of long-acting insulin use. Mild troponin elevation was determined to be related to demand ischemia. Nuclear stress test was performed and was normal. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The patient clinically improved with glucose and fluids and was discharged home the same day. 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 an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina

Treatment: Inpatient Admission

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

This is a female patient with a history of coronary artery disease (CAD), status post prior coronary stents, hypertension, hyperlipidemia, liver disease, asthma, obesity status post gastric bypass, and hypothyroidism. The patient presented to the Emergency Department with complaints of chest pain at rest and shortness of breath. She reported having episodes that lasted 30 minutes and they were relieved with aspirin and sublingual nitroglycerin. Cardiology consulted the patient. An electrocardiogram (EKG) was performed that showed normal sinus rhythm. Troponin levels were drawn with negative results. Recommendations were made to increase the patient's Imdur.  The patient was medically stabilized and discharged home with outpatient follow up instructions. 

Based on literature, this patient's HEART Score was 4, indicating moderate risk, or 12-16% likelihood of major adverse cardiac event (MACE) within the 6 weeks following assessment. Multiple studies recommend admitting patients with risk in this range. For this reason, an observation or inpatient hospitalization was warranted. The HEART score is a widely accepted method for standardizing a patient's risk in the setting of chest pain. While this patient required further evaluation and monitoring beyond the Emergency Department (ED) level of care, this patient did not meet the clinical guidelines for inpatient level of care. The patient did not have hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions that warranted acute inpatient level of care. Based on the review of this patient's plan of care, this patient could have been safely and effectively provided at the Observational level of care. Despite the patient's HEART Score of 4, this patient's non-diagnostic electrocardiogram (EKG) and cardiac biomarkers in the ED indicated that this patient's acute coronary syndrome was relatively low.

The health plan acted reasonably 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: Upheld

Diagnosis: Cardiac/Circulatory Disorders.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is: Upheld in whole.

The patient is a male with a history of hypertension, human immunodeficiency virus (HIV) infection. chronic kidney disease, cocaine abuse, cocaine-induced myocardial infarction, paroxysmal atrial fibrillation, and congestive heart failure with reduced ejection fraction. He presented to the hospital for elective catheter ablation of his atrial fibrillation. The procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. He remained hemodynamically stable. He was treated with ondansetron for emesis. He was discharged. Medical necessity for an inpatient stay is at issue.

The health plan's determination is upheld in whole.

This patient underwent transcatheter pulmonary vein isolation (PVI) procedure for paroxysmal atrial fibrillation. Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate of this procedure is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, most electrophysiologists admit patients for a period of monitoring post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. In summary, the patient could have been managed at a lower level of care status. An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skin disorders /Psoriasis.
Treatment:  Pharmacy Prescription drugs.
 
The insurer denied Skyrizi.  The denial is upheld in whole. 

The patient  with moderate to severe psoriasis (6% body surface area involvement) that includes the scalp, back, and knees.  The patient has tried and failed topical clobetasol, betamethasone, fluocinonide, and calcipotriene.

No, the requested Skyrizi is not medically necessary for this patient.

Modern dermatology literature [1-4] supports use of standard, first-line systemic therapies as similarly efficacious to the requested Skyrizi, particularly for a patient with little to no history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario.  The standard, first-line systemic therapies including Methotrexate, and/or light therapies are likely to work well for this patient, with both effectiveness and safety to treat this patient's psoriasis.  Therefore, as per current medical standards of care, Skyrizi is not medically necessary.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, alternative oral therapies, and/or Phototherapy.  Therefore, consistent with modern dermatology literature reviews [1-4], the requested Skyrizi is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and nausea (diverticulitis)
Treatment: Inpatient admission
The insurer denied the Inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a male. He presented to the emergency department of the facility filing the appeal with the complaints of left lower quadrant abdominal pain radiating to the back as well as nausea.  The patient had undergone a hydrocoele repair two days prior to this presentation. The patient reported the pain as eight out of ten. 

The patient's white count was 12.2. There was an episode of bradycardia to 53 beats per minute. A CT scan showed sigmoid diverticulitis. The patient was started on IV antibiotics and IV narcotic analgesia. The patient required a dose of Zofran. The patient was admitted for IV antibiotics, pain medication and supportive care. 

While the medical care was appropriate in all regards, the level at which this care was provided was not medically necessary, as explained in detail below.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection with sigmoid diverticulitis; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The patient was not on the correct treatment for diverticulitis after the outpatient surgery, so there was no failure of outpatient therapy. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Athetoid dystonic cerebral palsy GMFCS V; anoxic brain injury
Treatment: Tetrabenazine (xenazine) 12.5 mg tablet
The insurer denied the Tetrabenazine (xenazine) 12.5 mg tablet.
The denial is upheld.
The Tetrabenazine (Xenazine) 12.5 mg tablet is not medically necessary.

The patient is a male with history of athetoid dystonic cerebral palsy GMFCS (Gross Motor Function Classification System) V and history of anoxic brain injury. The patient was examined by the pediatric physiatrist. The patient's condition was addressed with a variety of medications, including, but not limited to, CBD (cannabidiol) oil, Sinemet, gabapentin. Hyperbaric oxygen therapy, stem cell transplant have been attempted as treatment modalities. Dystonia is the most prevalent functional impairment is being addressed with medications such as Onfi and Baclofen.  

The patient has been suggested variety of treatments for dystonia, including intrathecal baclofen pump.  He was started on a small dose of medication tetrabenazine (Xenazine) as an alternative treatment for dystonia. 

The Health Plan denied coverage for the prescription of the above mentioned medication due to the fact that prescription of this drug does not conform with the Clinical Policy Bulletin for dispensing of Xenazine which is indicated for:1) adult with documented chorea associated with Huntington disease, 2) documentation of ambulatory status 3) treatment of generic tetrabenazine has not been tried 4) patient does not have a serious untreated or undertreated psychiatric illness, or history of suicidal thoughts or behavior, concurrent use of monoamine oxidase inhibitors, reserpine or deutetrabenazine

There is anecdotal evidence supporting use of tetrabenazine in patients with pediatric chorea. There is no evidence to support use of tetrabenazine in children with dystonia. Therefore, the Tetrabenazine (Xenazine) 12.5 mg tablet is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Muckle Wells Syndrome

Treatment: Kineret (Anakinra)

The insurer is denied coverage for medication Kineret (Anakinra). 

The denial is upheld.  

Based on the review of the medical record, the patient was a male with sensorineural hearing loss and complete hearing loss in the left ear.  The only clinical documentation consist of letters of medical necessity stating that the patient had been recommended to receive Anakinra by a doctor for Muckle Wells Syndrome.  It is also stated that the patient had certain cytokines and HSP70 elevated.  Also included is a letter to the editor regarding Anakinra treatment in inflammasome disease (and a reply letter). Other than these documentations, there were no actual lab results included. There was no consultation note from a specified provider, and there was no mention of skin disease, which is typically a major feature in the Muckle Wells Syndrome.  There was also no mention of any inflammasome genetic abnormalities.  In summary, there was inadequate clinical evidence to support this patient's diagnosis of Muckle Wells Syndrome. Thus medical necessity for Anakinra is not supported by the documentation submitted for review. 

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

The carrier's denial of coverage for the medication Kineret (Anakinra) to treat Muckle-Wells syndrome is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post cardiac catheterization
 
Treatment: Inpatient admission 

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

This patient is a male with a past medical history of myocardial infarction, coronary artery disease, bypass surgery, diabetes mellitus, hypertension, and hyperlipidemia.  He presented to the hospital for an elective cardiac catheterization.  He had undergone an abnormal nuclear stress test and had worsening shortness of breath.  He underwent coronary angiography with coronary stenting to the right posterior descending artery and obtuse marginal branches.  There were no complications.  He was admitted and observed overnight, then discharged home.

The insurer has denied coverage for the inpatient admission.  Inpatient admission status is not medically necessary for this patient.  Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one.  The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate.  There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty.  Ambulatory surgery status following the procedure with up to 23 hours of monitored care would have been appropriate.

The health care 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 admission for acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral artery disease, diabetes
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.

This patient is a male, poorly controlled diabetic, with previous known peripheral vascular disease.  He was admitted to the hospital for elective lower extremity angiogram for claudication. High grade lesions were seen on an uneventful angiogram. Balloon angioplasty was performed with good results. The groin was closed manually and a small hematoma developed at the site; it was treated with direct pressure. The patient was admitted to telemetry was treated with intravenous fluids (IVF) and insulin. The patient was discharged on oral medications the next day.

This patient was electively scheduled for peripheral artery intervention due to probable claudication. He has had similar procedures previously. He was a poorly controlled diabetic (HgbA1c was markedly elevated on admission). The procedure was performed without complication per chart. A groin hematoma was conservatively managed. The patient was hemodynamically stable throughout. In the hospital he received IVF and insulin. Electrocardiogram (EKG) was normal. There was no evidence of diabetic ketoacidosis (DKA). He was discharged on his usual oral medications the next morning. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the intervention was planned, and performed uneventfully. (A groin hematoma following manual hold is common and was treated with direct pressure).   His glucose was high, and this was chronically the case, without DKA. No advance care was performed or was necessary.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of hemodynamic instability.  Milliman criteria requirements were not fulfilled as there was never any evidence of any condition requiring inpatient care. A small groin hematoma that is treated with pressure is not considered an operative site complication. His poorly controlled diabetes was present on admission and discharge.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mid and lower back pain -L4 and L5 region

Treatment: Chiropractic services.

The insurer denied coverage for chiropractic services. The denial upheld.

This patient is a female that sought treatment for ongoing mid and lower back pain.  According to the UR report, this patient had been treated by the provider 60 times for musculoskeletal complaints related to the neck, upper back and lower back. She returned for updated complaints and diagnoses of pain in the thoracic spine. The provider treated her mid to lower back pain during this time and the patient was also advised to apply moist heat and follow through on a home exercise plan (HEP), at home.

The insurer denied coverage for the above DOS by determining that the services were not medically necessary. The records indicated that the patient returned to the office for updated diagnoses of M54.6 (Pain in thoracic spine), M99.02 (Segmental and somatic dysfunction of thoracic region) and S23.3XXA (Sprain of ligaments of thoracic spine, initial encounter). These were the consistent diagnoses in the claims data from the DOS in question. A review of the records submitted indicated that the office note for a date of service specified finds the patient had complaints related to the mid back, with a reported pain level of 9 on a scale of 10 (10 being the worst).

By DOS specified the complaint was reported to be at a pain level of 5-6 on a scale of 10. The records for a subsequent indicated the patient had presenting complaints of mid and low back pain after "sleeping wrong on a different bed." The given pain levels on this DOS were 7-8 and 8-10 on a scale of 10 for the mid back and low back respectively and by another DOS specified these reported pain levels had reduced to 5 and 3 on a scale of 10 for the mid back and low back respectively.

The Council on Chiropractic Guidelines & Practice Parameters (CCGPP) guidelines indicates, "When the patient's condition reaches a plateau, or no longer shows ongoing improvement from the therapy, a decision must be made on whether the patient will need to continue treatment." The records submitted for review, reflecting the E/M service performed (99212-25) in question, did not support additional meaningful improvement in the patient's clinical condition to rationalize the need for ongoing chiropractic care.  It appears that the patient had achieved a plateau in treatment and continuation of treatment would suggest physician dependency.  Denial of the DOS in question appears to be appropriate. 

According to the documentation presented for review, the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  The chiropractic services were not considered medically necessary for this patient.

The carrier's denial of coverage for the chiropractic services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, pressure with shortness of breath and nausea
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

This patient presented with atypical chest pain and a past history of hypertension. His pretest probability of coronary artery disease is low (Reference 1). Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, he was considered low risk (1 point) (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1) (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3). Using the HEART score risk stratification schema, this patient would have a low 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. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.