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

Diagnosis: Right facial droop, left-handed weakness

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is overturned.

This case involves a patient who presented to the Emergency Department (ED) with complaints of right lower facial droop for 4 days and left-hand weakness. The documentation indicated she had a recent positive test for COVID-19 (2019 Novel Coronavirus). On physical examination, she was alert and oriented to person, place and time. Her blood pressure was 142/83 with a heart rate of 75 beats per minute (bpm). She had right-sided facial droop with 4/5 strength to the left upper and lower extremities. A chest x-ray was normal, and the computed tomography (CT) scan of her head revealed no acute intracranial abnormality. Laboratory studies revealed a white blood cell count of 6.8. She continued to test positive for COVID-19. A computed tomography angiogram (CTA) of the head and neck revealed no evidence of large vessel occlusion. The documentation indicated upon first reassessment she was alert and awake with no evidence of acute distress. The second reassessment did not reveal any changes. Hospital admission was recommended for further evaluation and treatment. She continued with additional treatment that included medication and further consultations. The patient did not have any further significant adverse events and therefore she was discharged the following day with instruction to follow-up.

From a neurological standpoint, a right facial droop, along with left-hand weakness is very concerning for a brainstem ischemic event. Such central nervous system (CNS) ischemic lesions can decompensate fairly quickly, leading to death. Hence, it was medically appropriate for admission, with frequent neurological checks to look for deterioration.

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

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ectopic pregnancy
Treatment: Inpatient stay

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

The patient is a pregnant female noted to have beta HCG (Human chorionic gonadotropin) 10,000 and no intrauterine pregnancy (IUP) on an ultrasound (US) in the provider's office. The patient's history was significant for a D&C (Dilation and curettage) x 2 and 1 spontaneous abortion. She was seen in the emergency department (ED), diagnosed with an ectopic pregnancy and signed out against medical advice (AMA).
The patient was then recalled to the ED. She reported scant vaginal bleeding. She was afebrile with stable vital signs: Pulse was 77, respiratory rate was 16; and blood pressure was 116 / 66. Abdominal exam was soft and non - tender. Hemoglobin and hematocrit were 13.1 and 39.9, respectively. The patient was admitted with plan for surgical management on the next morning.

The Inpatient Hospital Admission was not medically necessary for this patient. Based on the provided clinical information, the patient was hemodynamically stable, did not have any evidence of acute vaginal bleeding (vaginal bleeding was noted to be scant), did not have any peritoneal signs (abdominal examination showed soft and non - tender abdomen) and the clinical findings of unruptured ectopic pregnancy did not meet criteria for an inpatient level of care:
There was no documentation that monitoring beyond 24 hours of observation was required. The patient's care could have been performed at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: frequent falls
Treatment: Personal Care Aide (PCA) Level 2 Services
The insurer denied Personal Care Aide (PCA) Level 2 Services: Total Amount of 84 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, hypertension, neuropathy, gastroesophageal reflux disease (GERD), diabetes mellitus type 2, congestive heart failure, hypothyroidism, osteoarthritis, major depressive disorder, and urinary incontinence who had been assigned PCA (personal care aide) services following a telephonic assessment performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, and dressing lower body while limited assistance with tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With the task of eating, the patient was assessed as independent. The patient had 2 falls with the second resulting in a hospitalization for 3 days with diagnosis of left subdural hematoma and left intraparenchymal brain hemorrhage and she was noted to be COVID-positive. 

Personal Care Aide (PCA) Level 2 Services: Total Amount of 84 Hours per Week are medically necessary for this patient.
There is documentation that the patient had multiple falls, with 1 resulting in serious injury requiring hospitalization with brain bleeding. The assessment noted a decline in activities of daily living (ADL) status and deterioration of overall self-sufficiency. This assessment also noted increasing assistant needs with tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility when compared to a prior assessment tool. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient does not have informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The patient's family noted multiple inconsistencies with the assessment performed. The patient's hospital provider requested an increase in home health hours at discharge from the hospital. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg Pain. 
Treatment: Magnetic Resonance Imaging (MRI) scan. 

The insurer denied an MRI scan. The health plan's determination is overturned. 

This patient is a male with a complaint of right thigh pain. An office progress note documented that the patient noted pain in his right thigh 4 months earlier while playing softball. The physical examination revealed an intact quad tendon; however, a palpable defect was noted with resisted knee extension. The patient had normal strength and near full flexion. Plain radiographs of the right femur revealed no bony lesions or soft tissue calcifications. The orthopedic provider was concerned for a quadriceps tendon tear and referred the patient for an magnetic resonance imaging (MRI) scan of the right thigh. This is the subject of this review. 

The Magnetic Resonance Imaging (MRI) Scan of the Right Leg is medically necessary for this patient. The medical records document a clinical concern for a right leg quadriceps tendon tear based upon the patient's history of a leg injury while playing softball. The physical examination also documented a palpable defect in the quad tendon with resisted knee extension. Thus, the medical necessity of the requested MRI is established based upon the documentation in the records.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood Disorder-High INR/Low hemoglobin
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

This is a patient with a history of gastric carcinoma status/post (s/p) Roux-en Y, gastrointestinal (GI) bleed, recurrent pulmonary embolism (PE)/deep vein thrombosis (DVT), cerebrovascular accident (CVA), hypertension, hyperlipidemia, legally blind, asthma and depression who presented to the hospital emergency department (ED) after his doctor told him that his hemoglobin was low, and his international normalized ratio (INR) was 6. The patient was on injectable Lovenox and had bleeding on his injection site on his abdomen. Hemoglobin was 8.1, down from 12.9. Vital signs were blood pressure (BP) 117/54, pulse 97, temperature 97.1 Fahrenheit, respirations 20 and pulse oximetry 100% (percent). Physical examination showed mild bruises on his anterior abdomen. Abnormal laboratory values included hemoglobin 7.6, hematocrit 23.4, and INR > 10. A computed tomography (CT)scan of the abdomen and pelvis showed new nodular scarring in the low-anterior abdominal wall with subcutaneous air. CT scan of the brain did not show acute disease. The patient was admitted and given intravenous vitamin K. The next day the hemoglobin was 7.1 and INR 3.2. The patient left the hospital against medical advice. 

This patient presented to the hospital with low hemoglobin and elevated INR. The Lovenox was stopped, and the patient given intravenous vitamin K. On the following day, the hemoglobin was lower, and the INR had improved. There was no evidence of hemodynamic instability. There was no evidence of acute imaging findings. This patient had evidence of continued drop in hemoglobin and an elevated INR. He also had high risk conditions such as recurrent DVT/PE and required close monitoring since the Lovenox was being held. While there was no evidence of active bleeding, there was evidence of dropping hemoglobin. Based on current standards of care, given the significant drop in hemoglobin, it would be appropriate to continue frequent monitoring and further work-up of dropping hemoglobin in an inpatient setting in a patient with history of recurrent DVT/PE due to high risk of complications. The patient may have also required an inferior vena cava (IVC) filter since the Lovenox was being held. This patient required inpatient level of care due to continued drop in hemoglobin and high risk due to recurrent DVT/PE. Inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of tobacco abuse and psoriasis who was transferred from an outside hospital given her ongoing chest pain. The patient upon arrival she was hemodynamically stable, however, her lab results showed abnormal troponin levels. She was also found to have an abnormal electrocardiogram (EKG). She was started on intravenous (IV) Heparin as well as aspirin and Plavix. She underwent a left heart catheterization and the patient did not receive a stent. She was found to have diffuse small vessel disease and medical treatment was recommended. 
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary for this patient. This patient was transferred from other hospital and upon arrival, the patient was hemodynamically stable and her exam was unremarkable. The patient underwent coronary angiogram and she tolerated the procedure well. There were no intraprocedural adverse events. She remained stable throughout her hospitalization with no change in her clinical status. A lower level of care would have been appropriate for this patient. This decision is based on the current standard of care as well as the latest guidelines/literature available.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crowding; protrusion.
Treatment: Braces (D8080).
The insurer denied the Braces (D8080).
The denial is upheld.

The patient is a female. The request is for dental benefits for Braces. Per the provider's dental clinical summary, patient presents with a class III skeletal relationship, mild upper arch crowding, mild upper incisor protrusion, upper front teeth bite on the inside of the  lower teeth on the right side.

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report, the score necessary for braces approval.

The requested braces are not medically necessary.
Per the provider's dental clinical summary, the patient has a Class III skeletal molar relationship--indicating that the lower jaw is larger than the upper jaw. The position of the teeth are evidenced to be dictated by the skeletal relationship more so than malalignment of the teeth themselves.

In such a case, there are other parameters and treatments that need to be addressed prior to braces at this time.

The health plan acted reasonably with sound medical judgement and in the best interest of the patient.
The information submitted doe not support that braces therapy will remedy the patient's current dental conditions.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She presented to the ED (emergency department) for evaluation of abdominal pain and vaginal discharge. The patient has a history of bilateral ovarian cysts.

On initial evaluation, the patient was afebrile, vital signs were stable, and her exam was non focal. The patient was admitted for IV (intravenous) fluid hydration, observation and pain control.

The Inpatient admission was not medically necessary.
The patient had stable vital signs, a non-focal exam, and she was able to tolerate an oral diet and oral pain medication. She did not have any abnormal lab tests and did not have any medical conditions that would justify acute inpatient level of care as medically appropriate or necessary.

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

Coverage was denied by the health plan, because they contend the care rendered could have been provided at the observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periumbilical Abscess.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This patient is a female with a past medical history significant for gastroesophageal reflux disease (GERD), anxiety, postural orthostatic tachycardia syndrome, appendectomy, and cholecystectomy who presented to the hospital with complaints of abdominal pain.
It was reported that a few days before the day of admission the patient was admitted to the hospital for one day for administration of intravenous antibiotics, which were given due to umbilical abscess and cellulitis. She was discharged home with Keflex, which she took for at least six days. She was also using topical antifungal powder, topical Lidocaine, and Medihoney for wound care. The patient denied drainage or worsening signs of skin infection.

The inpatient hospital stay was not medically necessary for this patient.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Based on the current standards of care, the admission at the acute inpatient level of care in cases of cellulitis is recommended for the failure of outpatient treatment that is defined as progression or no improvement after an adequate trial of oral antibiotics, when outpatient intravenous therapy is not appropriate when patients present with hemodynamic instability, altered mental status, high-risk comorbid conditions, bacteremia, or some other circumstances.
There is no evidence that the patient's cellulitis was not improving. Furthermore, there was no evidence of a drainable abscess.
At the time of the initial evaluation, the patient was afebrile and had only mildly elevated white blood cell count. There was some erythema and an open sore related to the previously treated periumbilical abscess. It was clearly indicated in the note from the emergency department provider that the patient denied drainage or worsening signs of skin infection. Even though the patient reported nausea and chills, and there was no recorded fever. In addition, this patient denied vomiting, diarrhea, or any other symptoms.
The reason for her abdominal pain was not completely clear. Specifically, it was not clear if the pain was even related to resolving cellulitis.
Taking into consideration all these facts, it was reasonable to admit this patient for observation and provide treatment with pain medications and antiemetics.
However, the severity of the patient's condition and complexity of services provided did not justify admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: liver biopsy
The insurer denied a liver biopsy. The health plan's determination is upheld.

The patient is a woman who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy). The records support that she had a body mass index (BMI) of 40.5. The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of severe steatosis. Under review is the medical necessity of a liver biopsy.

The submitted documentation does not support the medical necessity of a liver biopsy at the time of roux en Y gastric bypass. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy.
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
In this case, the patient is morbidly obese with a body mass index of 40.5. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female in the first trimester who presented to the emergency room with right lower quadrant abdominal pain and vaginal bleeding. Her ultrasound showed an adnexal mass suspicious for ectopic pregnancy along with free fluid. The patient was admitted to the floor to await surgery in the morning. The patient underwent laparoscopic salpingectomy without documented complication. She was discharged right from the post-anesthesia care unit (PACU) after the surgery without reported complication.

The inpatient level of care for this patient was not medically necessary. The laparoscopic procedure was performed the day after admission and reported to have been performed as planned without intraoperative complication. That procedure is generally considered an outpatient procedure. There were no unexpected events, and she was discharged about 24hrs after the surgery ended. She required no serial testing or observation, and her vital signs were never unstable (American College of Obstetricians and Gynecologists (ACOG) criteria reports vital signs within 20% (percent) of baseline to be stable for discharge). There is no report of hemorrhage after the surgery. There are no notes from the resident or attending physician suggesting there was a plan to escalate care, continue observation, monitor the patient further, or keep her in the hospital another night. She was treated only with oral pain medication after leaving the recovery room (Percocet), and discharged after only one night in the hospital. Her vital signs were within normal limits for her entire stay (other than occasional outliers that were likely not accurate). The customary definition of inpatient care is that which cannot be provided as an outpatient safely. This patient was just waiting for surgery, which could have been done at a lower level of care. There was nothing in the notes to suggest that an inpatient level of care was indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Surgical Services.
The insurer denied liver biopsy as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient has a body mass index (BMI) 40 kilograms per square meter (kg/m2) and comorbid conditions of gastroesophageal reflux disease (GERD) and hypertension (HTN) who underwent a laparoscopic roux en y gastric bypass. Central obesity and fatty liver were identified intraoperatively, and a wedge biopsy was obtained from the left lobe of the liver. Pathology revealed macrovesicular steatosis. There is no preoperative clinical history for treatment of non-alcoholic steatohepatitis (NASH) / non-alcoholic fatty liver disease (NAFLD) or documentation of abnormal liver function.

The requested liver biopsy is not medically necessary for this patient. There is currently a lack of any national guideline from the American Society for Metabolic and Bariatric Surgery (ASMBS) or large high level prospective trial or randomized controlled trial (RCT) documenting any benefit from routine liver biopsy during bariatric surgery. In general, many individuals who undergo bariatric surgery may have suggestion of some degree of steatosis of the liver, observed intraoperatively, however, it is also well understood and documented in numerous publications that bariatric surgery and weight loss improves NASH/NAFLD. There are no clear outcomes benefit to perform liver biopsy in patients with normal synthetic liver function (lfts) or who do not carry a clinical diagnosis of NASH as most patients will not undergo subsequent re-biopsy of the liver to document improvement/progression. Separately, there remains controversy over the best method of liver biopsy. In general, when overall liver evaluation is sought, a long core needle biopsy (performed via tru cut or core needle) can provide better information about the parenchyma and can include multiple passes, 1 to 2 centimeter (cm) in length by approximately (~) 0.2 cm in width. Although wedge liver biopsy will afford a larger amount of overall liver tissue (tissue sample), it is often taken from the edges of the left lobe of the liver (which is more steatotic) are often subcapsular, and therefore may give the false impression of increased fibrosis. Although both are general safe procedures, there are known complications that can occur, primarily bleeding that do not support routine practice without a clear clinical indication of how the information is going to be tracked, utilized given that most patients will improve any degree of NASH/NAFLD after successful bariatric surgery/weight loss.