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

Diagnosis: Fall.
Treatment: Continued stay at a skilled nursing facility (SNF).
The insurer denied coverage for continued stay at a skilled nursing facility (SNF).
The denial is upheld.

This is a patient with chronic medical problems including hypertension, spinal stenosis and alcohol dependence.  His surgical history includes a right hip arthroplasty.  He was admitted to a skilled nursing facility after a fall, for occupational and physical therapy.  Under review is the medical necessity for continued stay at a skilled nursing facility (SNF).

The patient may have had impairments and functional deficits appropriate for the SNF subacute rehabilitation level of care (1, 2, 3).  However, there are no occupational therapy or physical therapy notes submitted for review documenting any specific clinical evaluation or treatment.  The provided clinical notes are insufficient to support the medical necessity for continued stay at a skilled nursing facility (SNF).  In addition, there were no specific acute medical or complicated nursing issues that required continued stay at the SNF for the time period under review.  

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a continued stay at a SNF is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain
Treatment:  Inpatient stay

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a woman who presented to the hospital with abdominal pain. She underwent a hemorrhoidectomy four days before this presentation and complained of difficulty with urination and painful defecation. The patient was evaluated in the emergency department and appeared alert-oriented with normal cardiopulmonary findings. The abdomen was overall soft and non-distended. There was no active rectal bleeding, and there was appropriate postoperative tenderness. 

The inpatient admission was not medically necessary. The patient had a low-risk surgical procedure, hemorrhoidectomy, and was experiencing postoperative constipation and urinary retention. Constipation resolved within the 24 hours that the patient was in the hospital. Still, the urinary retention persisted, and, therefore, she was treated with an indwelling Foley catheter and scheduled for outpatient voiding trials. Urinary retention is one of the most common complications of hemorrhoidectomy surgery. However, it is not a serious complication.

In general, there was nothing complicated about this hospitalization. There is no evidence of major surgical complications, bleeding, infection, wound dehiscence, etc. There is no evidence of intraperitoneal infection, bacteremia, ileus, or bowel obstruction. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Myocardial infarction.
Treatment:  Defibrillator Vest (ZOLL LifeVest).

The insurer denied a Defibrillator Vest (ZOLL LifeVest).  The health plan's determination is overturned. 

This man presented to the emergency department complaining of two days of chest pain. His electrocardiogram showed ST segment elevation and Q waves in the anterior leads, consistent with an acute ST segment elevation myocardial infarction. Emergent cardiac catheterization showed a 90% (percent), followed by an 80%, obstruction in the proximal left anterior descending coronary artery. 

The Defibrillator Vest (ZOLL LifeVest) was medically necessary.

Sudden arrhythmic death is common in the early post-myocardial infarction period, especially in the first 30 days. The risk is highest in patients with heart failure, left ventricular dysfunction, or both. Accordingly, there has been considerable interest in interventions that might modify this risk. Studies using anti-arrhythmic drugs have been disappointing. The DINAMIT trial (Defibrillators in Acute Myocardial Infarction Trial) was a multicenter, randomized, prospective study designed to assess the impact of implantable cardioverter defibrillator (ICD) implantation in addition to optimal medical therapy (OMT) versus OMT alone on all-cause mortality in high-risk patients within 40 days after infarction. Of 14,609 patients, 903 died suddenly, and 164 were resuscitated after cardiac arrest. The risk was highest in the first 30 days - 1.4 percent. There was no significant difference in all-cause mortality between the two groups. While the risk of sudden arrhythmic death was significantly lower in patients randomized to the ICD arm of the study than in the control group, this reduced risk was offset by an increase in non-arrhythmic death in the ICD arm of the study, compared with the control group. It is for this reason that current guidelines do not support ICD implantation in the early post-infarction period. A 40-day "waiting period" is recommended, in hopes that healing might result in improved left ventricular function; if revascularization is performed, a 90 day "waiting period" is recommended. In order to provide a "safety net" for high risk post-infarction patients, many physicians recommend the use of a WCD during this time. These devices have been shown to be highly effective in terminating ventricular tachyarrhythmias, with close to a 100% efficacy, resulting in "aborted sudden death" as opposed to sudden death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide: 7 Days per Week, Two 12-Hour Shifts per Day "Spit Shift".
The insurer denied Personal Care Aide: 7 Days per Week, Two 12-Hour Shifts per Day "Spit Shift".
The health plan's determination is upheld. 

The patient is a female with past medical history of osteoarthritis, osteoporosis, adrenal adenoma, history of pancreatic cancer with chronic pancreatitis, chronic kidney disease, goiter, diabetes mellitus type 2, hypertension, congestive heart failure, kidney stones, anemia, urinary incontinence, and bowel incontinence who had been assigned PCA (personal care aide) services.

Personal Care Aide: 7 Days per Week, Two 12-Hour Shifts per Day "Spit Shift" are not medically necessary for this patient.

There is no specific documentation from the patient, her family, or medical provider of specific care needs in the overnight hours that would not allow a PCA 5 hours of uninterrupted sleep. There were no overnight care logs provided for review documenting the specific care needs and timing of these care needs. There is no documentation from the patient's medical provider that the patient has the need for turning and repositioning every 2 hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 7 Days per Week, Two 12-Hour Shifts per Day "Spit Shift" are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, hypertension, heart failure, type 2 diabetes, hyperlipidemia, hypokalemia, fatigue

Treatment: Level 2 Personal Care Services, per 15 minutes increase to 42 hour(s) per week of consumer directed personal assistance services (CDPAS)

The insurer denied coverage for Level 2 Personal Care Services, per 15 minutes increase to 42 hour(s) per week of consumer directed personal assistance services (CDPAS)

The denial is upheld.

This is a patient with diagnoses of primary generalized osteoarthritis, hypertension, heart failure, type 2 diabetes, hyperlipidemia, hypokalemia, fatigue, gait and mobility abnormality, pain, and vitamin D (calciferol) deficiency.  The patient had a recent fall with a decline in his functional abilities. The most recent Uniform Assessment System (UAS) submitted indicates that the patient lives with spouse, can activate emergency plan, can make phone calls and is continent of bladder and bowels. 

The health care plan partially approves the increase in the patient's personal assistance services. It was determined that an increase from 28 hours per week to 32 hours per week was medically necessary based on a decline in his ability to perform a range of functional tasks including bathing, dressing, walking, using the toilet, managing medications, preparing meals, and doing housework and shopping. The request for an increase to 42 hours per week was denied. This decision was based on the plan's Tasking Tool (which provided standard recommended personal care hours based on the member's functional needs). It was noted that although the member did not have any recent emergency room (ER) visits, hospitalizations, or changes in family or social circumstances, the member did have a recent fall with a decline in his functional abilities. This decision by the health care plan is reasonable and medically sound based on the patient's functional status and the Tasking Tool.      

The provided documentation does not support the medical necessity for Level 2 Personal Care Services, per 15 minutes increase to 42 hours per week of consumer directed personal assistance services (CDPAS) for this patient. There is no evidence to support an increase in the patient's personal care services from 28 hours per week to 42 hours per week. The clinical documentation does not support an increase in personal care services to 42 per week as medically necessary. The appeal by the Attending Physician does not include any clinical information to support an increase to in personal care services to 42 hours per week. The Tasking Tool is a reasonable approach to determine the appropriate number of personal care hours based on the member's functional needs.

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 Level 2 Personal Care Services, per 15 minutes increase to 42-hour(s) per week of consumer directed personal assistance services (CDPAS) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, coronary artery disease, hypertension, diabetes, osteoarthritis, and hyperlipidemia. 
Treatment: 80 Hours Per Week of Consumer Directed Personal Assistance Services. 

The insurer denied: 80 Hours Per Week of Consumer Directed Personal Assistance Services. 

The denial is upheld. 

This elderly female has conditions including stroke, coronary artery disease, hypertension, diabetes, osteoarthritis, and hyperlipidemia. She is appealing the denial of 80 hours per week of consumer directed personal assistance services. The health plan approved an increase from 35 to 42 hours per week. The patient notes a recent fall and needing assistance with walking and transfers since the fall. Uniform Assessment System (UAS) evaluation completed 3 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, shopping, and lower body dressing; extensive assistance with bathing, upper body dressing, walking, locomotion, and toilet use; limited assistance with personal hygiene and toilet transfer; supervision with managing finances and medications, phone use; and independent with bed mobility and eating. She ambulates with a wheeled walker. She has frequent bladder incontinence. 
A recent clinical note states the patient presented with her daughter, who is a paid caregiver. The provider expresses concern of the daughter not providing the patient with the attention of care needed. 

The proposed treatment is not 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. The patient is appealing the denial of 80 hours per week of consumer directed personal assistance services. The health plan approved 42 hours per week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient needs limited to maximal assistance with activities of daily living, except managing finances and medications, phone use; bed mobility and eating. The patient reports a fall within the last 90 days. The clinical note does not support necessity for increase in personal assistance hours, but notes concern with current care being provided. The information does not support medical necessity for further increase in personal assistance hours from 42 hours per week. The approved 42 hours per week is sufficient to meet the patient's needs for assistance with activities of daily living. The proposed 80 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Full Hospital Admission.
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a female with newly diagnosed B-cell lymphoma who was admitted for inpatient care after the patient lost consciousness in the outpatient setting. The patient was admitted for inpatient care. While hospitalized, Cyclophosphamide, Doxorubicin (Adriamycin) Vincristine (Oncovin) and Prednisolone (a steroid) (CHOP) chemotherapy was administered and the patient was subsequently discharged.

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

The requested health service/treatment of a full hospital admission was not medically necessary for this patient. For well-appearing asymptomatic patients with an unclear cause of syncope but without high risk features, inpatient care is not required. The patient had a syncopal event in a stressful situation and lacked other high risk features including, but not limited to, an abnormal electrocardiogram (ECG), history of structural heart disease, persistently low blood pressure, shortness of breath, and a family history of sudden cardiac death. In this scenario, a full hospital admission is not required. The oncologic services rendered during the patient's hospitalization are typically provided at an alternate level of care including evaluation for leptomeningeal disease and administration of chemotherapy. Neither the peer-reviewed literature nor the authors of UpToDate recommend hospitalization in this clinical scenario and, therefore, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a man who presented to the emergency department (ED) with complaints of right upper abdominal pain of months duration. His past medical history is notable for diabetes. He was admitted to the hospital. Vital signs were normal at the time of presentation. He was tender in the right upper quadrant. Hepatobiliary iminodiacetic acid (HIDA) scan showed a high gallbladder ejection fraction of 84%. The surgical history and physical (H&P) states that the patient had a hyperkinetic gallbladder for which laparoscopic cholecystectomy was planned.

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with complaints of abdominal pain. Imaging and surgical consultation established the diagnosis of a hyperkinetic gallbladder for which cholecystectomy was recommended. At the time of presentation and at the time of surgical assessment, the patient had normal vital signs and was without fever.
Surgery (cholecystectomy) was performed. The perioperative and early post-surgical recovery were uncomplicated and the patient had normal vital signs and tolerated a diet following surgery. He was discharged from the inpatient setting following the initial recovery period. An acute inpatient hospital admission was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury (AKI)
Treatment: Inpatient admission
The health plan denied the requested inpatient admission.
The health plan's determination is upheld.

This case involves a woman with endocervical adenocarcinoma, who has completed radiation and chemotherapy and presented to the hospital with lightheadedness and weakness. The symptoms began after she completed her last brachytherapy treatment. She reported anorexia with poor caloric intake. She was maintaining hydration with water and electrolytes daily.

Vital signs in the emergency department showed a blood pressure of 123/50 millimeters of mercury (mmHg), a heart rate of 63 beats per minute (bpm), and respirations of 70/minute. On examination, she appeared nondistressed, with a normal cardiopulmonary exam and soft abdomen. Laboratory studies showed a normal white blood cell count and a hemoglobin of 10.5, a sodium of 139, a potassium of 2.9, and a creatinine was 2. The baseline creatinine was 1.4. In addition, the patient was hypomagnesemic at 1.3. A chest x-ray was unremarkable.

The patient was admitted to the hospital with acute kidney injury (AKI) due to suspected prerenal etiology and chronic diarrhea. She was started on gentle intravenous (IV) fluid hydration. Potassium and magnesium were being replenished. Physical and occupational therapy was consulted to evaluate.

The following day, the patient denied pain, nausea, or diarrhea episodes. Vital signs appeared stable, and the exam was unchanged. Repeat labs showed significant improvement in the potassium at 3.4, and the creatinine decreased to 1.65. FENa (fractional excretion of sodium) was calculated at less than 1%, consistent with prerenal etiology. Additional potassium was given. The Obstetric/Gynecology team described the patient as euvolemic on the exam. The patient ambulated through the hallways, tolerated a regular diet and was cleared for discharge home.

The question is the medical necessity for the requested inpatient hospital admission. I fully uphold the health plan's determination of medical necessity. Inpatient hospitalization is not warranted in this case.

Based on the provided documentation, there is no indication for an inpatient hospital admission. The patient had prerenal AKI, with less than a threefold increase in creatinine. The patient's kidney function improved with appropriate intravenous fluids and encouragement of oral intake. FENa, less than 1%, indicates prerenal etiology, with expected improvement and low risk of progression to renal replacement therapy. The electrolyte derangements responded appropriately to supplementation and nearly normalized within 24 hours of admission. There were no worrisome EKG changes correlating with the electrolyte disturbances. This type of presentation can be managed under an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Inpatient Hospital Services. 

The health plan denied the requested inpatient hospital services as not medically necessary. 

The health plan's determination is upheld. 

This patient is a male who presented with back pain. His history was significant for obesity, spinal stenosis, chronic anticoagulation on Xarelto, and chronic back pain on outpatient opioids. He was hemodynamically stable, afebrile, not hypoxic, and tolerating an oral intake. He had no red flag signs of cord compression on the exam. There were no significant abnormalities in the labs. The emergency department (ED) physician treated him with pain medication. 

At issue is the medical necessity for inpatient hospital services. 

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

The requested health service/treatment of inpatient hospital services was not medically necessary for this patient. 

The patient presented with acute on chronic back pain. His pain was controlled with ED management and the admitting physician noted no need for inpatient care the next day. 
The patient was clinically stable. His pain was well controlled. The admitting physician increased his pain medication orders and noted an existing plan for an outpatient pain management appointment and no need for inpatient imaging or pain management. He was able to ambulate with physical therapy. The patient was discharged home. 
This patient had no evidence of clinical instability, and his treatment could have been safely and appropriately delivered at an alternate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis of right knee.
Treatment: Computer-Assisted Surgical Navigation.
The insurer denied Computer-Assisted Surgical Navigation for Musculoskeletal Procedures.
The denial is overturned. 

The patient is a female who underwent a right total knee arthroplasty with use of robotic assistance for arthritis of right knee. The computer-assisted surgical navigation for the procedure has been denied. This request was previously denied as 20985 (computer-assisted surgical navigation) is unproven and not medically necessary. The operative report states that the surgery was performed with robotic assistance.
At issue is the medical necessity of Computer-Assisted Surgical Navigation for Musculoskeletal Procedures.

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

Yes, the requested health service/treatment of Computer-Assisted Surgical Navigation for Musculoskeletal Procedures was medically necessary for this patient.
As noted in the article from the Journal of Knee Surgery, robotic-assisted total knee arthroplasty is associated with less use of articular constraint, shorter length of stay, and fewer manipulations under anesthesia with no increase in complications when compared to manual total knee arthroplasty. As noted in the article from Arthroplasty Today, patients undergoing robotic-assisted total knee have earlier discharge and higher likelihood of discharge home instead of discharge to a subacute rehabilitation facility when compared to patients undergoing conventional total knee arthroplasty. As noted in the referenced article from the Bone and Joint Open Journal, patients undergoing robotic assisted total knee arthroplasty have lower pain levels at both rest and with activity, request less opioid medication, and have a shorter length of stay than patients undergoing conventional total knee arthroplasty. As noted in the referenced review article from StatPearls, robotic total knee arthroplasty has better surgical and clinical patient outcomes than conventional total knee arthroplasty.
In this case, the patient underwent a right total knee arthroplasty with use of robotic assistance. There is current medical literature that indicates that this approach is efficacious and superior to the conventional technique without robotic assistance.
Therefore, the requested health service/treatment of Computer-Assisted Surgical Navigation for Musculoskeletal Procedures was medically necessary.