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

Diagnosis: family history of breast cancer
Treatment: genetic testing
The insurer denied Genetic Testing for Breast and Ovarian Cancer Susceptibility (CPT [current procedural terminology] 81433, 84480).
The health plan's determination is upheld. 

The patient is a female with Ashkenazi Jewish heritage who desires genetic testing for breast cancer antigen (BRCA) 1/2. Her grandmother had breast cancer prior to age 50 and her mother was positive for BRCA mutation. She had two previous tests that showed BRCA positive gene defect and had a third test with her insurance prior to her hysterectomy and mastectomy. She had the Breast and Ovarian cancer multigene cancer panel (current procedural terminology (CPT) 81433, 84480). 

Genetic Testing for Breast and Ovarian Cancer Susceptibility (CPT 81433, 84480) is not medically necessary for this patient.
American College of Obstetricians and Gynecologists (ACOG) recommends testing in patients without a personal history of cancer when one of the following has been met: a first degree relative or several close relatives that meet the criteria, a close relative with a known BRCA 1/2 mutation or a close male relative with breast cancer. The patient has no personal history of cancer and a mother with the BRCA gene. Therefore, she would meet the criteria for BRCA testing; however, the patient did not have single gene testing. She had multigene genetic cancer screening. Pre and post testing counseling must be available and performed prior this testing to ascertain the necessity of the multi-gene testing. There is no evidence that this was accomplished. ACOG recommends that referral to a specialist in cancer genetics or a health care provided with expertise in genetics is recommended for expanded gathering of family history information, risk assessment, education and counseling which may leave to testing and tailored cancer screening or risk reduction measures, or both. Multigene panels are not currently recommended for one cancer risk history and their usefulness has not been well-established.
Per the National Comprehensive Cancer Network (NCCN) guidelines, multigene panel testing is supported in patients without a personal history of cancer when they have a first or second degree relative with breast cancer prior to age 45, ovarian cancer, male breast cancer, pancreatic cancer, metastatic prostate cancer, two primary tumors or three family members with cancer. The patient does not meet these guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergic Reaction.
Treatment: Inpatient Hospital Stay.

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

This is a female patient with a past medical history of Type 2 diabetes, sleeve gastrectomy, gastroesophageal reflux disease, iron-deficiency anemia, obstructive sleep apnea, endometriosis, and depression/anxiety who presented with multiple symptoms. These symptoms included chest pain, shortness of breath, back pain, abdominal pain, lip and tongue numbness, itchy throat, dysphonia, and dizziness during an intravenous iron infusion at the hematology clinic. The patient reported that the infusion rate seemed faster than during the previous session and that she experienced a similar but less intense reaction after the first infusion earlier in the month. 
The patient appeared uncomfortable but not in distress, with a subdued affect. 
The patient's hospital course involved a diagnosis of an allergic reaction to intravenous (IV) iron sucrose. Her airway remained patent, and her respiratory status was stable. She received steroids and antihistamines in the emergency department and underwent a flexible laryngoscopy that revealed reflux.  At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient's presentation at the hospital was suggestive of an allergic reaction to the intravenous iron infusion. However, despite these symptoms, the patient did not exhibit signs of severe anaphylaxis and maintained stable hemodynamics with normal oxygen saturation throughout the evaluation. There were no indications of life-threatening symptoms in the patient's condition.
The patient's symptoms experienced significant resolution within a timeframe that aligns a standard observation period. There was no evidence to suggest delayed or recurrent symptoms, and the patient's condition did not necessitate the administration of intravenous medications beyond an observation period. While the patient's long-standing gastrointestinal symptoms possibly warranted an endoscopic evaluation, the esophagogastroduodenoscopy (EGD), could have been safely conducted at a lower level of care. Admission to the acute inpatient level of care was not necessary for this procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

The patient had a history of complicated diverticulitis and presented with left lower quadrant (LLQ) abdominal pain. The patient was recently treated with outpatient Augmentin for diverticulitis. The patient was afebrile and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. An abdominal computed tomography (CT) scan was obtained and revealed diverticulitis that was largely unchanged. There was air adjacent to the bladder and colon but no discrete fluid collection. No fistula was seen at this time. Intravenous (IV) ceftriaxone and Flagyl were given. No surgical intervention was advised at this time. The patient was discharged on oral antibiotics. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality on an imaging study. This abnormality can be a fistula, obstruction, or free perforation such as air under the diaphragm. The patient did not have these conditions. The patient also did not require a drainage procedure, have bacteremia, severe vomiting, or an inability to maintain oral hydration after observation care. 

This patient had diverticulitis and did not respond adequately to Augmentin. The patient required additional antibiotics, but this could have been started with observation care. Afterwards, the patient could have been discharged on oral Cipro and Flagyl. The patient did not have a fistula or a free perforation during this admission. There was only a walled off contained perforation adjacent to the bowel. The patient did not meet MCG criteria for admission for acute care for Diverticulitis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Congenital vascular malformations. 
Treatment: Sirolimus powder compound. 
The insurer denied coverage for Sirolimus powder compound. 
The denial is overturned. 
 
The patient is an adult male with a diagnosis of congenital vascular malformations with painful blebs. The patient has had symptomatic relief from the use of compounded topical sirolimus cream for two years. The request is for formulary exception for the continued use of compounded topical sirolimus. 

The plan's final adverse determination relates to formulary exception. The plan did not provide a list of formulary drugs that they consider appropriate to treat the patient's condition, thus this review must determine if the non-formulary drug being denied is clinically appropriate for the patient's condition. 

Based on the information provided, the use of compounded topical sirolimus is clinically appropriate for the treatment of the patient's rare congenital disorder which involves vascular malformations and vascular blebs. There are no Food and Drug Administration (FDA) approved medications for the patient's diagnosis. The patient requires treatment for symptomatic relief and to improve everyday functioning. The use of sirolimus for vascular malformations is clinically documented in the medical literature. The lack of FDA approved clinical options as well as the lack of formulary alternatives necessitate the use of compounded sirolimus in this clinical scenario. The patient has been treated with some success and no documented adverse reaction to topical sirolimus for 2 years. The use of compounded topical sirolimus is approved. 

The carrier's denial of a request for a Formulary Exception for Sirolimus powder compound is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brain cancer, hydrocephalus, COPD (chronic obstructive pulmonary disease), and seizures
Treatment: Stair Lift
The insurer denied: Stair Lift
The denial is overturned.

The patient is an adult male. He has multiple conditions, including brain cancer, hydrocephalus, COPD (chronic obstructive pulmonary disease), and seizures. Denial of a stair lift is being appealed. The patient is receiving PCA (personal care aide) services 42.5 hours per week. He lives with his spouse, who provides informal support. His spouse provides informal support and assists the stairs. The patient uses a wheelchair for ambulation. UAS (Uniform Assessment System) evaluation shows that he requires total dependence with locomotion. An appeal statement notes that the patient is wheelchair bound. He has six steps leading to the entrance. He uses the back entrance that has few steps. He cannot navigate the stairs alone. His wife 
alternates moving the wheelchair and a chair between steps (photos reviewed). He has had 3 falls in 90 days.

The requested Stair Lift is medically necessary.

This patient requires total dependence with transportation. He is wheelchair bound. He is unable to independently stand or ambulate. He is dependent with stairs. The patient has stairs to his home that cannot be accommodated with a ramp. His wife is using an unsafe alternative of alternating the wheelchair and a chair to get him downstairs and out of the house. She has no additional assistance. The use of transportation services significantly limits the patient's ability to leave the home, except 
for medical appointments. The requested stair lift is medically indicated for the patient's safety in leaving the home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, heart failure, hypertension, diabetes neuropathy, degenerative joint disease, and lumbar radiculopathy.
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) to 56 Hours per Week.

The insurer denied Increase Consumer Directed Personal Assistance Services (CDPAS) to 56 Hours per Week.  The denial is overturned.

The patient is an elderly male. His medical conditions include coronary artery disease, heart failure, hypertension, diabetes neuropathy, degenerative joint disease, and lumbar radiculopathy. He had a fall 8 months ago that resulted in a right hip fracture. He was discharged from a SNF (skilled nursing facility) 7 months ago. He lives alone. Denial of increase consumer directed personal assistance services (CDPAS) to 56 hours per week is being appealed. The health plan approved 35 hours per week. The patient's Uniform Assessment System evaluation performed 5 months ago shows the patient has modified independent cognition and requires extensive to maximal assistance with all ADLs (activities of daily living), except limited assistance with personal hygiene, upper body dressing, and eating. He has occasional bladder incontinence.

Appeal statements report that the patient's conditioning is worsening. The patient needs assistance with ADLs (activities of daily living), including nighttime assistance with toileting and incontinence care every one to two hours. He is at risk of falling.

The requested Increase Consumer Directed Personal Assistance Services (CDPAS) to 56 Hours per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase consumer directed personal assistance services (CDPAS) to 56 hours per week is being appealed. The health plan approved 35 hours per week. The health plan denied the increase in hours and recommended physical therapy for strengthening, as well as DME (durable medical equipment). The plan notes CDPAS (consumer directed personal assistance service) is not indicated for safety supervision. The patient has multiple chronic conditions, including recent hip fracture. Uniform Assessment System (UAS) evaluation completed 5 months ago shows he is independent all ADLs (activities of daily living). He has bladder incontinence. Appeal statements report a decline in his functioning. These statements support the need for assistance with ADLs (activities of daily living), including frequent toileting. The information provided supports that the patient has significant functional limitations. He needs frequent assistance with ambulation and toileting. The approved CDPAS (consumer directed personal assistance service) 35 hours per week is insufficient to meet this patient's needs and frequency for assistance with ADLs (activities of daily living). The requested CDPAS (consumer directed personal assistance service) 56 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Massive weight loss
Treatment: Ambulatory surgery (outpatient services 15830 x1)
The insurer denied: Ambulatory surgery (outpatient services 15830 x1)
The denial is upheld.

This adult patient has lost 100 pounds following bariatric surgery. Since her massive weight loss surgery, she was left with a symptomatic abdominal pannus. She notes that the weight of her pannus causes friction, causes irritation and frequent rashes which are not relieved with over-the-counter creams and powders. Her pannus hangs below her mons pubis, which causes some difficulty with ambulating as well. She denies abdominal pain, chest pain, shortness of breath, fevers, or chills. The patient is a nonsmoker. Panniculectomy is planned.

The proposed treatment is not medically necessary.

The panniculectomy is not medically necessary. The medical records do not provide documentation in the form of primary care physician (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. 
According to the American Society of Plastic Surgeons guidelines, "Patients considered for panniculectomy should document the type and duration of symptoms/treatment for panniculitis and photographs should confirm the patient's medical condition." 
Supervised medical management for rashes is not documented in any of the progress notes. Photos showing the abdominal pannus are not provided. The patient writes in her appeal letter that she does not have open sores or skin breakdown due to good hygiene practices. In a multiple regression analysis of postoperative complications after body-contouring surgery 
written by Parvizi et al. the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2% (percent). In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscence. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and patient appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coffee ground emesis, anemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a medical history of hypertension, hyperlipidemia, and opioid abuse. He presented to the emergency department with coffee-ground emesis for two days and heartburn, fatigue, dizziness, weakness, dyspnea, and constipation. He had a similar episode a month prior. He was treated with intravenous fluids, Unasyn, pantoprazole, and folate. He was transfused with two units of packed red blood cells. He was advanced to a clear liquid diet.  He was tolerating a diet without emesis. An esophagogastroduodenoscopy showed esophagitis with ulceration, a small hiatal hernia, and gastritis. He was discharged. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not medically necessary based on the submitted documentation, and the care provided could have been provided at a lower level of care.
The patient presented with coffee-ground emesis and symptomatic anemia. However, he had a good response to blood transfusion, and there was no ongoing bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-6]. An esophagogastroduodenoscopy showed esophagitis and gastritis, but did not show any high-risk stigmata or ongoing bleeding, and no immediate endoscopic intervention was necessary [1-6]. He was evaluated for abnormal imaging of the lungs and mediastinum, and to treat with empiric intravenous antibiotic, but no significant intervention was recommended. All of the measures that were undertaken, including monitoring, labs, transfusion, gastroenterology consultation, endoscopy, and proton pump inhibitor therapy, could have been performed in sequence after presentation and without acute inpatient level of care. [1-6].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left upper extremity numbness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department with concerns for left upper extremity numbness and slurred speech. The pertinent history included atrial fibrillation and migraine headache.  The initial examination documented the patient as awake and alert with a National Institute of Health Stroke Scale (NIHSS) of 1. A computed tomography (CT) scan of the head was unremarkable. Computed tomography angiography (CTA) of the head/neck was unremarkable. Additional laboratory testing, later on, included an alcohol level which was elevated at 327. The patient was admitted to the hospital with an impression of presenting symptoms likely related to alcohol intoxication with plans to rule out an acute cerebrovascular accident (CVA). The treatment plan included intravenous fluids and additional diagnostic tests such as magnetic resonance imaging (MRI) of the brain and an echocardiogram. The echocardiogram was relatively unremarkable. The MRI of the brain ruled out acute ischemia but did note a few nonspecific punctate foci of increased T2 signal within the cerebral white matter. The patient was feeling better and denied any symptoms. Neurology followed up and noted the symptoms were likely related to migraine. A cerebrovascular accident was ruled out. The patient was discharged. At issue is the medical necessity of inpatient hospital services.

Based on the clinical documentation provided, evidence-based literature, and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient has a history of migraine headaches and presented with left-sided numbness and slurred speech. Initial computed tomography (CT) of the head imaging was unremarkable. Laboratory testing revealed an elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), and elevated alcohol level. The admitting physician had an impression of presenting symptoms related to alcohol intoxication. No significant withdrawal symptoms were noted and benzodiazepines were not provided. Additional diagnostic testing including an echocardiogram and MRI (magnetic resonance imaging) brain were also unremarkable. Following overnight observation care, symptoms resolved, and the patient was discharged. The neurologist had an impression of a migraine headache. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Infection
Treatment: inpatient emergency admission
The insurer denied the inpatient emergency admission. 
The health plan's determination is upheld.

The patient was a male with the chief complaint of "fever, not eating, coughing" for 2 days. He was noted to have decreased urination, feeding and activity. He was also noted to have a non-itchy, non-painful rash over his right lower abdomen. He presented to the emergency department (ED) and was assigned an Emergency Severity Index (ESI) at level 3. His medical history was notable for prematurity and acute otitis media. There was no history of prior wheezing or chronic lung disease. The ED provider documentation does not list intake/output (I/O) details, but nursing admission note reports "mother states patient has not voided for 2 days except small amount in emergency room (ER)."
The patient was admitted to the inpatient floor. His admission note states "on exam he appears in no apparent distress (NAD), viral syndrome, continue intravenous fluids (IVF)" and "unremarkable examination findings except for dry oral mucosa." A plan was made for "vitals as protocol, as tolerated pediatric diet, maintenance IVF of dextrose (D5) normal saline (NS) with potassium chloride (KCL), as needed (PRN) Tylenol." Following admission, the patient received Benadryl for the rash.  The patient was discharged home on as needed acetaminophen and to follow up with his pediatrician. His problem list per discharge summary listed "dehydration, poor feeding, viral infection."
At issue is the medical necessity of inpatient emergency admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient emergency admission was not medically necessary for this patient.
The physical examination described in the documentation provided is not consistent with severe dehydration nor acute respiratory distress. The patient did not require frequent breathing treatments, supplemental oxygen or ventilatory support requiring inpatient admission. (1-4) His lungs were reportedly clear which is not consistent with a diagnosis of bronchiolitis (4) and his chest radiograph did not show pneumonia. He appropriately received IVF normal saline (NS) boluses in the ED but there is no documentation that a by mouth (PO) trial was made and failed. His bloodwork showed no significant electrolyte abnormalities or metabolic acidosis requiring inpatient admission.
This patient's physical exam and history are notable for a report of decreased urine output and dry mucus membranes. His vital signs and physical exam in the emergency department otherwise were unremarkable and are not consistent with severe dehydration requiring hospital admission. There were no clinical findings to suggest more than mild dehydration as the patient was described as having "dry lips" only.