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

Diagnosis: Anemia 
Treatment: Hospital admission
The insurer is denied coverage for hospital admission. 
The denial is upheld.

This is a male patient with a history of polysubstance abuse who presented to the emergency Department (ED) with hematuria. The patient had a history of anemia and required transfusions. At that time it was recommend the patient have a colonoscopy; he refused. The patient denied gastrointestinal (GI) bleeding. In the ED, the patient's vitals were: temperature 98.5, blood pressure 171/86, pulse 84, respiratory rate 20 and oxygen saturation of 100% on room air. The patient's abdominal exam was benign. The patient's hemoglobin was found to be 5.7; he was transfused 2 units of packed red blood cells. An endoscopy was scheduled twice but the patient refused the procedure and was noncompliant with the procedure requirements of not eating. After the blood transfusions, the patient's hemoglobin had improved to 8.5. There was no active bleeding noted during this patient's inpatient stay. The patient was discharged with an appointment for a gastroenterology follow up.

According to MCG guidelines for Anemia (M-35), clinical indications for admission for anemia include hemodynamic instability, active bleeding, altered mental status, cardiac arrhythmias, severe thrombocytopenia, acute renal failure, and signs of cardiac ischemia. However, in this case, the patient did not have these conditions. The patient was hemodynamically stable with no chest pain or shortness of breath. On exam, the patient was not in acute distress, alert and oriented.

This patient had chronic anemia for which the patient's hemoglobin level was responsive to blood transfusion. The patient's anemia was stable and there was not active bleeding. Inpatient admission was not medically necessary. The patient could have received his blood transfusion in the Emergency Department or in the Observation level of care, rather than being admitted to inpatient status. The patient's endoscopy could have been scheduled as an outpatient. The patient did not meet the MCG criteria for admission for an iron deficiency anemia.

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

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

Diagnosis: Left Hip Dysplasia 
Treatment: Factor V Leiden test
The insurer denied coverage for Factor V Leiden test.
The denial is upheld.
This is a male patient who underwent closed reduction (casting) for left hip dysplasia. It is noted in the records reviewed that the patient's mother had Factor V Leiden (FVL) with no mention of thrombotic events; the patient's father was noted to be healthy. It appears that this Factor V Leiden test was requested by this patient's pediatrician and with the Orthopedics as per a handwritten addendum. However, no orthopedics records were available for review.

According to literature review, maternal history of FVL noted in the medical record, is not an indication for genetic testing. Multiple peer reviewed articles, including those provided by the pediatrician in this appeal, have not shown the indication (merit) and how this testing, at this patient's age, would change the outcome for the projected procedure, which was casting/closed reduction of the hip. On the review on the attestation for external appeal, the doctor writes that "this is the correct test to do", however that assertion does not make it medically necessary. Given the records provided for review, this test was not medically necessary as it would not have affected the outcome of this patient's procedure to be performed. According to the American College of Medical Genetics Consensus Statement on Factor V Leiden Mutation Testing, the "screening of asymptomatic individuals with other recognized environmental risk factors such as surgery, trauma, paralysis, and malignancy is not necessary or recommended, since all such individuals should receive appropriate medical prophylaxis for thrombosis regardless of carrier status." Thus, the Factor V Leiden test performed was not medically necessary for this patient.

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 Factor V Leiden test performed should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular 
Inpatient hospital 

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

This case involves a man with a history of coronary disease with bypass grafting, cardiomyopathy with an ejection fraction of 25% and a history of stroke with residual right hemiparesis and aphasia, who presents to the emergency department with right facial tightness. The symptoms were noted by the patient's mother, who noted worsening aphasia and facial asymmetry and some left-sided weakness, which began the morning of the presentation. The last known baseline was the night before. The patient is unable to provide any history due to aphasia. He was brought into the emergency department, where a stat head computed tomography (CT) showed no acute abnormalities. A computed tomography angiography (CTA) of the carotids was also done stat, which did not show any acute occlusion. 

The inpatient hospital admission is not medically necessary for this patient. There is no clear evidence that this patient suffered a new stroke. A CT scan of the head is negative. A CTA is negative, as well. The documentation from multiple physicians, shows no new focal neurologic deficits, to suggest an acute stroke. There is no evidence of hemodynamic instability. The focal neurologic symptoms are residual from a previous stroke. There is no new finding on brain imaging, to require inpatient care. There is no alteration of mental status. There are no cardiac arrhythmias of immediate concern. There is no documentation on the CTA to suggest arterial dissection. The patient did not require parenteral anticoagulation. As a result, there is no indication for an inpatient hospitalization. A lower level of care is appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Pregnancy/Childbirth
Inpatient Hospital

Diagnosis: Pregnancy
Treatment: Inpatient Hospital Stay. The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a pregnant female at 34 4/7 weeks gestation. She was referred due to oligohydramnios - amniotic fluid index (AFI) 3 cm; biophysical profile (BPP) was 6/8. EFW (estimated fetal weight) was 2252 g (grams). Her obstetrical history was significant for 2 NSVD (normal spontaneous vaginal deliveries). The second was complicated by oligohydramnios at term. The patient was hemodynamically stable. Cervix was closed.

The Inpatient Hospital Admission was medically necessary for this patient. Based on provided clinical information, the patient developed oligohydramnios at 34+ weeks gestation.
According to available literature evidence, oligohydramnios at this gestational age can result in cord compression (manifested by fetal heart changes - variable decelerations, bradycardia in extreme cases), and lead to fetal compromise and, in extreme situations, in-utero fetal death. The fact that the patient had Category 1 fetal heart rate tracing on admission does not guarantee that the fetal heart rate tracing does not deteriorate.
The standard, generally accepted approach by OB/GYN and MFM (Maternal Family Medicine) community in the USA, is admission for continuous fetal monitoring, IV hydration, administration of steroids for fetal lung maturity and immediate access to the operating room (OR) if fetal compromise is noted on fetal monitoring and cesarean delivery is indicated. This level of care/interventions cannot be achieved at an observational level of care. Therefore, admission to the acute inpatient level of care was medically appropriate and necessary and is supported by the literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep apnea
Issue under review: Continued CPAP

Determination:
The Continued CPAP is not medically necessary.

The patient is an adult male who was prescribed CPAP (continuous positive airway pressure). Per the provided documentation, the patient has been using the CPAP for 16 months, but claims that he has not received any supplies. The DME (durable medical equipment) company insisted that they have sent him three. There was no compliance data provided for the days leading up to the requested dates of service. The request is for continuation of CPAP coverage. 

Due to lack of data available which includes compliance and adherence data for the dates for which the continuation of services have been requested, the health plan acted reasonably and with sound medical judgment.  In order to help obtain optimum health benefit from the use of the CPAP, more than 70% of the nights need use of the mask and machine for more than four hours.  Even though some data was provided, the patient reports that he did not receive any supplies for 16 months whereas the DME company states that they have sent him three.  In addition there was no compliance data provided for the days leading up to the requested dates of service.  Therefore, medical necessity is not supported at this time.
Appeal type: Medical necessity
Decision: Overturned

Genetic Diseases - Other
Cancer Screening

The patient is a female with a family history of breast cancer involving 2 maternal aunts, a maternal grandmother diagnosed with breast cancer, a paternal aunt diagnosed with breast cancer, and a paternal cousin diagnosed with breast cancer. She also has a maternal uncle who is deceased from pancreatic cancer. The patient has no personal history of breast cancer although she has undergone percutaneous breast biopsies in the past.
The patient underwent myRisk Hereditary Cancer Genetic testing due to her family history of cancer and the inability of affected family members to be tested. Her only living affected family member was undergoing active treatment for intestinal cancer and was not available to undergo testing.
The question at hand is whether or not myRisk Hereditary Cancer Genetic Testing was medically necessary for the patient.

The health plan's determination is overturned.

The requested health service/treatment of myRisk Hereditary Cancer Genetic Testing is medically necessary for the patient. The patient has a strong family history of breast cancer and her affected family members are not available to undergo testing themselves.
The patient is an unaffected female with a strong family history of breast cancer. Her affected relatives are not available to undergo genetic testing because they are either deceased or, as in the case of her maternal aunt, unavailable for testing due to ongoing active cancer treatment. According to the American Society of Breast Surgeons Consensus Guideline on Genetic Testing for Hereditary Breast Cancer, "When it is not feasible to test the affected relative first, then the unaffected family member should be considered for testing if they are interested, with careful pre-test counseling to explain the limited value of 'uninformative negative' results".
Additionally, the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology - Genetic/Familial High-Risk Assessment: Breast, Ovarian and Pancreatic, states under "Hereditary Cancer Testing Criteria", that testing is clinically indicated in the scenario of an unaffected individual with a first- or second-degree relative who meets any of the listed criteria. One of the listed criteria is exocrine pancreatic cancer at any age. The patient's maternal uncle is deceased from pancreatic cancer. Therefore, the patient meets the NCCN testing criteria for high-penetrance breast and/or ovarian cancer susceptibility genes.
For both of these reasons, myRisk Hereditary Cancer Genetic Testing is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Family history of 
Treatment: 81163 - BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis, full sequence analysis 

The patient is a female without a personal history of cancer. She has a notable family history of triple negative breast cancer in her mother diagnosed before the age of 50,  a paternal great aunt also diagnosed with breast cancer before the age of 50, a paternal cousin who died at age 42 from breast cancer, and was recommended genetic testing for BRCA1 and BRCA2.  

There are no data from peer reviewed literature to show that BRCA1 and BRCA2 testing in this setting is clinically indicated or medically appropriate; it is not standard of care and it is not supported by professional organizations. Thus the BRCA1 and BRCA2 testing was not medically necessary.  

There are no data that testing in this case would improve outcomes or be clinically indicated.  Based on peer reviewed data and on professional society guidelines, BRCA testing is medically necessary in patients without cancer when they have three or more relatives on the same side of the family with breast cancer, two or more relatives on the same side of the family with epithelial ovarian cancer, one close relative with both breast and ovarian cancer, a close male relative with breast cancer, one first degree relative with bilateral breast cancer, one first degree relative diagnosed with breast cancer at age 45 or younger or risk of mutation documented as ten percent or higher. In this case, none of these criteria are met, and thus based on peer reviewed data, on what is determined to be standard of care and on professional organization recommendations, the Plan acted reasonably and with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The proposed treatment was not medically necessary.

The patient is a female who presented with chief complaint of vaginal bleeding and dizziness. She was diagnosed with symptomatic fibroids. Vital signs were stable and her hemoglobin was 10.2. She was admitted and started on oral progesterone.

This patient was complaining of dizziness; in other words, she was symptomatic for anemia. This patient did not fulfill the transfusion guidelines for use of blood components as her hemoglobin as more than 8.0 grams per deciliter (g/dl).  

It is unclear why this patient was admitted as nothing was done during this admission. She received iron pills and progesterone. Both could have been given as an outpatient. Even if the patient needed transfusion, blood transfusion does not require admission.

This patient could have been evaluated in the ED. If the provider felt that she was symptomatic for anemia, she could have been transfused and sent home or if transfusion was not necessary then she could have been given or prescribed high dose estrogen to stop the bleeding with a follow up within 24 hours with her primary physician or gynecologist.

Nothing was done in the hospital that could not be done as an outpatient.

MCG list the clinical indications for inpatient care for patients with anemia; these include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, and/or syncope. This patient did not have any of these. 

Based on all of the above, the admission from was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/Metabolic /Nutritional/Obesity 
Surgical services 

This patient that is 65.75 inches tall, weighs 222.4 pounds a body mass index of 36.2 kilograms per meters squared (kg/m2)). The patient has weight related co-morbid conditions that include sleep apnea and severe degenerative joint disease (DJD) of the knee (unable to get a knee replacement secondary to her weight), gastroesophageal reflux disease (GERD), and asthma. The patient completed a dietary and psychological evaluation that did not reveal any barriers to surgery. The patient has failed dietary efforts in the past. Medical clearance was obtained. The health plan's determination of medical necessity is overturned in whole.
Yes, the requested treatment and inpatient admission are medically necessary for this patient.
This patient meets all standard nationally accepted criteria for bariatric surgery, including the National Institute of Health (NIH) consensus guidelines, Centers for Medicare and Medicaid (CMS)/National Coverage Determination (NCD) and the American Society for Metabolic and Bariatric Surgery. The patient is an adult with body mass index (BMI) that is at least 35 kg/m2 (it is 36.2 kg/m2) with an associated weight co-morbid condition of sleep apnea. The patient has failed dietary efforts and completed a multidisciplinary evaluation that did not reveal dietary, psychological, medical or surgical barriers.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with advanced dementia, hypertension, urinary incontinence, hypothyroidism and chronic kidney disease. The patient had been assigned 36 hours of personal care assistance (PCA) services per week and the patient's daughter attends to the patient on non PCA service hours. The patient's daughter was hospitalized and subsequently at her discharge was unable to provide the level of informal care that was provided to the patient before. The patient's family and physician were requesting an increase in PCA service hours. In its final adverse determination letter, the health plan noted "you are reporting you have some issues, however, the change in medical condition is not major. The reported change does not impact your current personal care needs." The health plan denied coverage for PCA services for the requested 72 hour/week.

The health plan's determination is overturned. 

The personal care assistance for 72 hours is medically necessary. The patient's daughter was an informal caregiver for the patient but she was hospitalized herself and was not able to provide the level of care she had been able to previously provide to the patient. The patient's provider felt an increase in PCA services was medically necessary and specifically noted the patient required total care for bathing and moving from bed to chair.
In an office visit note the patient's primary care physician (PCP) noted the patient had reduced tolerance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs); more specifically, that she needed total care for transfer in and out of tub and moving from bed to chair. The provider also noted that the patient needed assistance with dressing, eating, transferring on/off toilet and cleansing after toileting with cleaning of the commode/bedpan. The patient had an assessment tool performed without the daughter present, noting independence with bed mobility and eating. Limited assistance was required with walking and locomotion. The patient required extensive assistance with tasks of dressing upper and lower extremities, personal hygiene, bathing, stairs, transportation and toilet use. The patient required maximal assistance with managing medication, phone use and equipment management. On assessment, the patient had total dependence for meal preparation, ordinary housework and managing finances. On the assessment it was noted that the daughter manages and administers medication. The assessment also noted that the patient was observed going in and out of the bathroom yet documented an unsteady gait and balance concerns. The patient was noted to be alert and oriented times one (x 1) but scored 0/30 on the Mini-Mental State Examination (MMSE). After the  assessment, the health plan kept the PCA service hours at 36 hours/week.
With an MMSE of 0/30 the patient would need much more assistance with managing medication, walking, locomotion, toilet use, personal hygiene and eating than noted on the assessment tool.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain Injury

Treatment: Continued Inpatient Rehabilitation

The insurer denied continued inpatient rehabilitation. The denial was upheld. 

This is a young male patient with a history of pulmonary atresia (hypoplastic right heart with intact ventricular system, right ventricle dependent coronary circulation), status post modified external conduit non-fenestrated Fontan, plastic bronchitis, developmental delay, right multi-cystic dysplastic kidney with left hydroureteronephrosis, renal calculi, right subdural empyema requiring emergent craniotomy with external ventricular drain. He sustained an acquired brain injury, complicated by bradycardic cardiac arrest with suspected anoxia, seizures, dysphagia, and chronic sinusitis. The patient was admitted to a rehabilitation facility for intense rehabilitation including physical, occupational and speech therapy/feeding therapy. Upon admission, it was reported that the patient required a nasogastric feeding tube (NGT) to supplement his oral intake. His physical exam revealed that he was awake and alert, unable to speak clear words with generalized weakness. He was unable to stand and required 2 person maximum assist for transfers, and all aspects of activities of daily living (ADLs). He received physical, occupational, and speech therapy with positive results. His speech improved and he was speaking in full sentences. The patient met the set inpatient rehabilitation goal and was then discharged home with outpatient rehabilitation. 

The patient has met his inpatient Rehab goals and therefore has plateaued. It is therefore not medically necessary for the patient to receive acute intense rehabilitation at the facility. It has been documented that the patient was safe to go home since he has met all his inpatient goals. In his PT notes the patient was able to transfer supine to sit and sit to stand independently. He ambulated 20 feet with the front walker with assistance and stood with contact guard with the front walker for 30 seconds. He is manageable at a lower level of care and therefore is safe to transition to an outpatient setting. Notes show that the patient can be discharged to continue outpatient therapy at the facility. MCG Recovery Facility Care Guidelines were used to make this determination. 

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

Based on the above, the medical necessity for the continued inpatient rehabilitation stay is not substantiated. The insurer's denial is upheld.