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

Diagnosis: Syncope. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This is the case of an adult female patient that presented to the hospital following an episode of syncope. Past medical history was significant for migraine headaches and remote Lasik eye surgery. On the day of presentation, the patient noted irritation and pain around her right eye. She reported that she was standing, turned around, felt some pain in her eye and fainted. In the Emergency Department (ED) she reported blurry vision in the right eye. Vital signs on presentation were stable (blood pressure [BP] 133/85, pulse 85 beats per minute). Physical examination was unremarkable. Ophthalmology evaluated the patient and found no evidence of ocular pathology. Electrocardiogram (EKG) revealed normal sinus rhythm without ST (intervals on EKG) or T (intervals on EKG) wave abnormalities and normal QRS (intervals on EKG) axis and conduction intervals. Computed tomography (CT) scan of the head revealed no abnormalities. Echocardiogram was completely normal and demonstrated no valvular pathology and a preserved left ventricular ejection fraction (LVEF) (55%[percent]) with no regional wall motion abnormalities. Serum blood testing revealed no elevation in troponin. Serum blood urea nitrogen (BUN) was 18 and creatinine (CR) 0.58 consistent with volume depletion. The patient was admitted to the hospital for observation. She was noted to be orthostatic and treated with intravenous (IV) fluids and subsequently discharged home. 

According to the American Hospital Association/ American College of Cardiology/ Heart Rhythm Society (AHA/ ACC/ HRS) guidelines, such patients should be managed utilizing a structured ED observational protocol (1) In a study of individuals presenting to the emergency room, patients that were low-risk or intermediate-risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing. (2) In this case, the patient had a normal echocardiogram and a normal 12 lead EKG. The clinical presentation was consistent with an etiology of volume depletion. 

This patient presented with syncope that occurred while standing and noting eye pain. Physical examination revealed no major abnormality and serum blood testing revealed an elevated BUN/CR ratio. A 12 lead EKG revealed no abnormalities. Echocardiography revealed a structurally normal heart with a normal LVEF. This patient falls into a low-risk group for syncope. 

The health plan acted reasonably and with sound medical judgement and in the best interest of the patient. Acute inpatient admission was not necessary. 

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

Diagnosis: Generalized weakness, a fall, sinus congestion, and postnasal drip. 
Treatment: Inpatient admission. 

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

The patient is a female with diabetes, gastroparesis, and hypertension. She was admitted with generalized weakness, a fall, sinus congestion, and postnasal drip. 

On presentation, the patient was afebrile the blood pressure 92/63 and pulse 87. After intravenous fluid administration in the emergency department the blood pressure was 109/67. Labs were notable for a BUN (blood urea nitrogen) 33, glucose 237, creatinine 1.9, potassium 4.5, and white blood cell count 20,600. Chest x-ray and computed tomography of the spine and brain demonstrated no acute process. Intravenous fluids were provided and diuretics were held. Symptoms resolved and white blood cell count normalized. The creatinine dropped to 1.5. A renal ultrasound showed no hydronephrosis. 

No, the Inpatient admission was not medically necessary. 

The patient's generalized weakness was not accompanied by a focal neurologic process, acute cerebrovascular accident, seizure activity, or change in level of consciousness. Radiographic imaging studies of the spine, playing, and chest showed no acute finding. The patient had only a modest degree of acute kidney injury. Renal function improved promptly with intravenous fluid administration. There was no hyperkalemia, uremia, acidosis, or volume overload. The white blood cell count promptly normalized. The patient remained afebrile and hemodynamically stable without evidence of infection. In summary, inpatient admission was not medically necessary. 

As detailed above, inpatient admission on the dates in question was not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: left total hip replacement

Treatment: inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization.

The denial is modified. 

This male patient has a history of cholecystectomy, hernia repair, asthma, Crohn's disease, psoriatic arthritis, chronic back pain, Lyme disease.

The records show the patient's post surgical course was complicated by pain. He required intravenous (IV) Morphine on several occasions. The medication was provided on post surgical day #1 and #2. His dizziness and inability to be mobilized should be taken into consideration to substantiate the admission. He was not able to be treated at a lower level of care. His pain was not manageable with oral analgesics. He would not be able to receive the multiple dosages of Morphine at a lower level of service. His condition had improved and was ready for discharge. Thus, the health plan acted reasonably in part.

Based on the above, the denial of the inpatient hospitalization is modified. Reverse denial of inpatient stay 2 days and uphold denial of 2 days.  

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

The carrier's denial of coverage for the inpatient hospitalization is modified.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a male with a history of EtOH (alcohol) abuse, cirrhosis, withdrawal tremors, seizures, and depression.  He presented for epigastric pain, nausea, and several episodes of vomiting with red streaks in it.

The patient had O2 (oxygen) saturations up to 77% while sleeping.  Pulmonary was consulted for a possible sleep study.  The patient's hemoglobin was 6.6 status post one unit of packed RBCs (red blood cells). Clear liquids were started and advanced as tolerated.

A few days later, the patient was deemed stable to be discharged home.

No, the inpatient admission was not medically necessary.
The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

An inpatient level of care was not required, as the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, did not have an elevated white count, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

Based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question, as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata/Totalis

Treatment: Xeljanz

The insurer denied coverage for Xeljanz.

The denial is overturned.

The patient has a diagnosis of alopecia areata/totalis.  She has failed topical and traditional therapies, including spironolactone oral as well as multiple topicals.  The patient was provided with Xeljanz.  The combination of several months of therapy with Xeljanz and minoxidil has led to significant hair regrowth.  The patient has not experienced any documented adverse reactions.  

The patient is currently stable with her current regimen.  It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following months of use which has resulted in disease remission without significant adverse effects.  As a result, the denial is overturned and the use of Xeljanz is medically necessary for use in the treatment of the patient's condition.  The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

Based on the above, the medical necessity for the Xeljanz is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I, Class II canines, maxillary and mandibular spacing, and anterior crossbite with gingival attachment loss

Treatment: Braces (comprehensive orthodontic treatment)

The insurer denied coverage for braces (comprehensive orthodontic treatment).

The denial is upheld.

Upon review of the submitted documentation including lateral cephalothin radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, Class II canines, maxillary and mandibular spacing, and anterior crossbite with gingival attachment loss. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. 

Upon review of the submitted documentation, (study models are not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity of orthodontic are, a HLD Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of crossbite, gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD Index of the insurer attaining 6 points (3 overjet, 2 overbite, 1 labio-lingual spread).

Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The insurer's denial of coverage for orthodontic care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female patient who has a history of chronic abdominal pain, hypomagnesemia, a stage 4 sacral decubitus ulcer, hypertension, severe protein calorie malnutrition, chronic UTIs (urinary tract infection), iron deficiency anemia, anxiety, a history of bilateral nephrostomy tubes, a chronic indwelling foley catheter, history of a colostomy, and a chronic femoral head fracture. The patient has a history of chronic abdominal pain from abdominal surgery.  The patient has a retained foreign body. The patient has had VRE (vancomycin-resistant enterococci) and MRSA (methicillin-resistant Staphylococcus aureus).  The patient then returned that day for the report of bright red blood in her colostomy bag. She reported thirst, nausea, emesis, and abdominal pain. The patient was requesting pain medication. She reported she could not eat and could not care for herself at home.  The patient was noted to be somnolent and had received narcotic pain medication.

For the dates of service under review the patient again had an extensive history as above. This presentation, she complained of LLQ (lower left quadrant) abdominal pain at the ostomy site and associated nausea and emesis.  The patient reported no fevers or chills. The patient noted that the pain was similar to prior presentations. The patient's foley and nephrostomy tubes were functioning well.

The patient reported she required fluids and pain medication and that she could not tolerate oral intake.

No, the Inpatient admission was not medically necessary.
The care as provided was not medically necessary for this patient who had just been discharged from a hospital setting. The patient evidenced no acute changes or needs on this presentation.

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 numerous chronic conditions, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged 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.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis.
Treatment: Custodial Care.
The insurer denied the Custodial Care.
The denial is overturned.

This patient is an adult female with multiple conditions including cellulitis, leg pain, hypertension, xerosis, diabetes, hyperlipidemia, and constipation.  She had been recently hospitalized with right lower extremity cellulitis.  She is appealing denial of custodial (long term) care. The request was denied because the patient was able to have needs met in a community setting.   

The patient was admitted to a facility.  She was clinically stable. She was on a regular solid diet.  There were no falls.  She was continent.  Medications had been established. Functional status shows contact guard assistance (CGA) with mobility and ambulation, minimal assistance with wheelchair mobility, minimal assistance with transfers, and modified independent with dressing.  There is no significant change through her stay.

Yes, the Custodial (Long Term) Care: was medically necessary.
This patient has multiple chronic conditions and had been hospitalized with lower extremity cellulitis.  The patient was transferred to subacute rehab.  During the period in question the patient was clinically stable.  She was not receiving skilled nursing care.  She was ambulatory and able to perform activities of daily living (ADLs) with contact guard assistance (CGA) to minimal assistance.  The care she was receiving was consistent with custodial care.  Custodial care is care primarily for the purpose of assisting a patient in activities of daily living (ADLs) or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury.  The custodial level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is the case of a patient with a past medical history of osteoarthritis, glaucoma, and cataract, who presented to the Hospital for right total hip arthroplasty. The patient was admitted as an inpatient to Orthopedic Surgery Service. The patient underwent total arthroplasty of the hip with acetabular and proximal femoral prosthetic replacement, without autograph. Post-operatively, the patient was evaluated by Physical Therapy (PT) and Occupational Therapy (OT). The patient had complaints of dizziness and was orthostatic with PT and received a bolus of fluids. The patient was discharged with home health care.

The medical records demonstrate the patient reported feeling dizzy after PT. She had received a bolus of 1 liter normal saline. The facts were surgery was non complicated with an operative time of 1 hour and 20 minutes. She had a blood loss of 150 cubic centimeters (cc). She did not require a drain. 

She was American Society of Anesthesiology (ASA) class 2 and did not require treatment for an underlying medical condition. Her vital signs were stable with no evidence of hypotension nor tachycardia. Her reported pain levels were 0. She was able to tolerate oral pain medications. She was evaluated by PT on the day of surgery and was able to do steps. Subsequent PT records noted ability to walk 450 feet. 
The physician noted the need for bolus of intravenous (IV) fluid but also reported disposition to home. The records show no evidence of hemodynamic instability nor necessity for additional care. 

The services could have been provided at a lower level of care. There were no extenuating circumstances to substantiate the admission. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Acute Cholecystitis. 
Treatment: Full hospital admission. 

The insurer denied coverage for full hospital admission. 

The denial is upheld. 

This is the case of a female with history of migraines and COVID (coronavirus) 19 who presented to emergency room (ER) with complaints of nausea, vomiting, and abdominal pain.  The patient was admitted. The patient presented to the emergency department (ED) with the complaint of vomiting, diarrhea and abdominal pain. The patient was afebrile with stable vital signs. As per the ED provider note the patient presented with complaints of sudden onset of right upper quadrant (RUQ) pain which was crampy in nature accompanied by nausea and vomiting. On exam she was afebrile with the abdomen soft and non-distended with Murphy's sign present in the RUQ. White blood count (WBC) was 8.9. and alkaline phosphatase was 67 with a total bilirubin of 0.8. Abdominal sonogram revealed a mildly distended gall bladder with cholelithiasis and mild gallbladder wall thickening. The plan disposition was to admit to surgery. The patient was given a clear liquid diet on, as well as IV (intravenous) Zosyn. Surgery saw the patient with the note updated and noted the history and lab tests with the plan for OR (operating room) for lap cholecystectomy and admit to surgery with NPO (nothing by mouth) past midnight. 

Progress notes indicated the patient was lying comfortably in bed with mild pain and denying nausea or vomiting. The abdomen was soft with mild RUQ tenderness. 

The patient was taken to the operating room underwent an uneventful lap cholecystectomy.  Post op the patient did well with stable vital signs and was discharged with outpatient follow up. 

Based upon the records the full inpatient hospital admission was not justified as this patient could have been managed in an ambulatory/observation setting as she did not have elevated WBC, fever, or abnormal LFT's or a confirmatory test to show that she had acute cholecystitis. She did not meet criteria for an acute admission for acute cholecystitis as she could have been managed in an observation/ambulatory setting as noted by the insurer. 

According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical care- 25th edition Gall bladder or bile duct inflammation or stone the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of this patient as the patient did not meet criteria for admission but rather ambulatory/observation status. Denial is upheld. 

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Invasive ductal carcinoma (IDC) of the left breast

Treatment: Radiation Therapy

The insurer is denied coverage for Radiation Therapy.

The denial is overturned. 

This female patient has a history of invasive ductal carcinoma (IDC) of the left breast.

Clinical data indicate good clinical tolerance to proton therapy without unexpected complications. Proton beam therapy had acceptable toxicity for reradiation for breast cancer, which has a much higher risk of side effects (Thorpe et al.). Several institutions have reported early outcome data, notably the groups at Massachusetts General Hospital (MacDonald et al.), the Procure Proton Therapy Center in New Jersey (Cuaron et al.), and the Florida Proton Therapy Institute (Bradley et al.).  These first publications unanimously reported good tolerance with no increased skin or cosmetic toxicities using standard fractionation schedules at generally accepted total dose levels. They confirmed in clinical practice that indeed a mean heart dose of 2 gray (Gy) relative biological effectiveness (RBE) is rarely exceeded.  Kammerer et al. concluded that proton therapy often decreases the mean heart dose by a factor of 2 or 3, i.e., 1 Gy with proton therapy versus 3 Gy with conventional 3Dimensional conformal radiation therapy (RT) and 6 Gy for intensity-modulated radiation therapy.

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

The carrier's denial of coverage for the Radiation Therapy is overturned.  The medical necessity is substantiated.