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

Diagnosis: Respiratory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female who presented to the emergency department with concerns for shortness of breath for several weeks. Pertinent history included hypertension.
Initial vital signs revealed a temperature of 97.8 Fahrenheit (F), heart rate (HR) 91, blood pressure (BP) 164/75, respiratory rate (RR) 20, peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination documented the patient alert and oriented with clear breath sounds. Initial laboratory testing revealed a white blood cell (WBC) count 11.1, hemoglobin (Hgb) 12.5, platelets (Plt) 325, blood urea nitrogen (BUN) 9, creatinine (Cr) 0.7, sodium (Na) 142, potassium (K) 4.2, glucose (Glu) 88, carbon dioxide (CO2) 24.5, brain natriuretic peptide (BNP) within normal limits, Troponin negative, D-dimer within normal limits. Electrocardiogram (EKG) was unremarkable. Chest radiograph was unremarkable. Computed tomography angiography (CTA) of the chest revealed a left lower lobe pulmonary nodule and left lower lobe pulmonary artery branch attenuation likely due to motion artifact, but possible a pulmonary embolism. A lung perfusion scan was performed which noted low probability of a pulmonary thromboembolism. Cardiology consultation was obtained who had an impression of chest pain, dyspnea, and nonproductive cough for one month associated with hemoptysis. Recommendations were for an echocardiogram and/or cardiac stress test. The patient was admitted with an impression of chest pain and hemoptysis. Treatment plan included admit to observation/telemetry, echocardiogram, stress test, and pulmonary consultation. The patient was afebrile, hemodynamically stable, and without hypoxia. Pulmonary consultation was obtained who had an impression of likely asthma / chronic obstructive pulmonary disease exacerbation. Recommendations included cough suppressants and systemic steroids. The patient was discharged to home.

The inpatient stay was not medically necessary for this patient.

In this particular situation, the patient presented with chest pain and shortness of breath. Initial evaluation found the patient to be afebrile, hemodynamically stable, and without hypoxia. Laboratory testing and imaging were essentially unremarkable except a computed tomography (CT) angiogram of the chest noted possible motion artifact versus a pulmonary embolism. A lung perfusion scan ruled out a pulmonary embolism shortly after. Cardiology recommended an outpatient cardiac evaluation. Pulmonary recommended cough suppressants and systemic steroids. Following observation care, the patient was deemed medically stable for discharge. No other issue or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: difficulty walking.
Treatment: home health care.
The insurer denied Customer Directed Personal Assistance Service Hours: 58 Hours per Week. 
The health plan's determination is overturned. 

The patient is female with past medical history of vascular dementia, depression, hyperlipidemia, gastroesophageal reflux disease (GERD), urinary incontinence, osteoporosis, hypertension, and osteoarthritis who had been assigned CDPAS (Customer Directed Personal Assistance Services).

Customer Directed Personal Assistance Service Hours: 58 Hours per Week are medically necessary for this patient.
There is documentation from the patient's primary care provider, her healthcare advocate, and from the previous assessment that the patient has had a decline in physical and cognitive functioning. There is no documentation of improvement in the patient's cognitive or physical functioning yet the insurer reduced her hours of CDPAS services. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use with unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested maintenance of CDPAS service hours is not solely for safety and supervision but to assist the patient with safe completion of ADL (activities of daily living) and IADL (instrumental activities of daily living). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Although the insurer recommended physical therapy the patient had already completed this in the past.
Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 58 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: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs/ Humatrope.
The insurer denied Humatrope. 
The denial is overturned.

The patient is a male. This request is for Humatrope. His growth hormone (GH) stimulation test with arginine and clonidine peaked at 25. His Insulin-like growth factor-binding protein 3 (IGBP3) was 3160 (1828-6592); Insulin-like Growth Factor 1 (IGF1) was 84 (100-449). His IGBP3 was 2950 (1828-6592); IGF1 was 106 (100-449).
His weight was 25.4 kilograms (kg).
His height was 122 cm (-2.36 standard deviation score [SDS]). 
His mother's height is 170.18 cm and father's height is 175.26 cm and mid parental height is 179.22 cm (+0.33 SDS).
The subject under review is the medical necessity for Humatrope.

The health plan's determination is overturned.

The requested Humatrope 12 milligrams (mg) cartridge is medically necessary for this patient. GH is indicated for the treatment of GH deficiency in certain patients who do not fail GH stimulation tests based on the Lawson Wilkins Pediatric Endocrine Society (LWPES) alternate criteria [2] which state, "No gold standard exists for the diagnosis of growth hormone deficiency (GHD). Although children severely affected by GHD fail GH stimulation tests, there is no doubt that some children with GHD achieve stimulated GH concentrations above the arbitrary cutoffs that have been applied. A trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests, but who meet most of the following criteria: (1) height greater than 2.25 standard deviation (SD) below the mean for age or greater than 2 SD below the mid parental height percentile; (2) growth velocity less than 25th percentile for bone age;(3) bone age greater than 2 SD below the mean for age; (4) low serum insulin-like growth factor 1 (IGF-I) and/or insulin-like growth factor binding protein 3 (IGFBP3); and/or (5) other clinical features suggestive of GHD."
This patient met criterion 1 as pretreatment height was -2. 3 6 SD. IGF1 was low. Height velocity is less than the 25th percentile. The patient therefore met 3 of the above criteria. The patient therefore meets criteria for the diagnosis of growth hormone deficiency.
The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting, Dehydration.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient presented to the emergency room for the acute onset of vomiting and diarrhea. He was noted to be dehydrated in the emergency room and was admitted for hydration and further management. The patient received intravenous fluids and gradual diet advancement.
At issue is the medical necessity of an inpatient admission.

The admission at the acute level of care was not medically necessary.
The patient had evidence of acute gastroenteritis leading to vomiting, diarrhea, decreased oral intake and dehydration. The current standard of care in the management of acute gastroenteritis and dehydration is supportive care. The patient was unable to consume adequate fluids or maintain hydration. He required intravenous fluids and slow diet advancement.
However, the care could have been provided safely and effectively at a lower level of care than inpatient. The care only included intravenous fluids and diet advancement. He did not have hemodynamic instability or severe electrolyte abnormalities. He did not have an ileus or bowel obstruction. There was no severe acidosis or respiratory compromise and no renal failure or end-organ damage. The patient did not require surgical interventions or complex therapeutic regimens.
Therefore, the care could have been provided at a lower level of care. An acute level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. T
he insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with medical history of anemia. She presented to the emergency department with three weeks of right upper quadrant and epigastric pain radiating to her back, worse with eating. She had two similar presentations to the emergency department in the prior two weeks. Gastroenterology consultation concluded that she had abdominal pain secondary to untreated gastroesophageal reflux disease (GERD) or gastritis from non-steroidal anti-inflammatory drugs (NSAIDs); the recommendation was proton pump inhibitor daily, avoid NSAIDs, correct electrolyte abnormalities, and antiemetics if nauseous. She reported no diarrhea since presentation; her pain was subsiding. Labs showed low hemoglobin of 10.4 g/dL and hematocrit of 31.2%, and unremarkable comprehensive metabolic panel. She was not found in her bed, and was thought to have eloped. She was discharged on pantoprazole, with a plan for Gastroenterology follow-up. At issue is medical necessity for the inpatient level of care.

The health plan's determination is upheld in whole.

The inpatient level of care is not supported as medically necessary. In this case, the patient presented with epigastric pain and right upper quadrant abdominal pain radiating to her back, and imaging showing a dilated common bile duct. This was consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) or gallbladder disease; however, there was no sustained tachycardia or hypotension, cholecystitis, cholangitis, acute pancreatitis, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction; follow-up imaging did not show choledocholithiasis [1-6]. She was appropriately treated with proton pump inhibitor therapy, and endoscopy was not deemed necessary [4-6]. Although she was anemic, there was no gastrointestinal bleeding, hypotension, hemodynamic decompensation, or drop in hemoglobin. She ultimately eloped from the hospital. All of the measures that were undertaken, including monitoring, labs, Gastroenterology consultation, and proton pump inhibitor therapy, could have been performed without the inpatient level of care, at a lower level of care status [1-6].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic brain injury, tension headaches, dizziness, fatigue, Raynaud's disease, and anisometropia

Treatment: Durable Medical Equipment (Walk in Tub)

The insurer denied coverage for Durable Medical Equipment (Walk in Tub)

The denial is upheld

This is a patient with chronic medical problems including Raynaud's disease, vision impairment, dizziness, and headaches with history of traumatic brain injury. She requires extensive assistance from 1 helper for bathing. She ambulates using a cane or walker. Under review is the request for Durable Medical Equipment (Walk in Tub).

The clinical records do not support the medical necessity of the requested walk-in tub. According to a letter from her treating physician, the patient reportedly has a "medical need for a Whirlpool Hydro Jet Heated Immersion Therapy Walk in Tub" in order to "address her diagnoses and symptoms". However, the physician's assertions regarding the therapeutic effects of hydrotherapy are neither specific to the patient's condition nor supports its medical necessity. In addition, the Uniform Assessment System (UAS) report, indicates the patient requires extensive assistance from 1 helper for bathing. As such, the helper can assist the patient with bathing with the use of a transfer tub bench or shower chair.  

From a physical medicine and rehabilitation perspective, the requested Durable Medical Equipment (Walk in Tub) is not medically necessary.  

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

The insurer's denial of coverage for Durable Medical Equipment (Walk in Tub) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute renal failure

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is the case of a male admitted for acute renal failure secondary to obstructive uropathy and underwent urology evaluation and foley placement. His condition responded appropriately with good urine output and improving creatinine and he was discharged in stable condition.

This patient was noted for abnormal kidney function; however, his condition was responding to intravenous fluid which more consistent with prerenal azotemia with urine retention and no signs of severe renal damage or irreversible condition such as vasculitis or ischemic acute tubular necrosis and he did not require renal replacement therapy.

His condition could have been safely treated under lower of care.

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

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

Diagnosis: CVA. 
Treatment: Home health care. 

The insurer denied Personal Care Assistance Services: 56 Hours per Week. 
The health plan's determination is overturned. 

The patient is a male with past medical history of hypertension, cerebrovascular accident (CVA), benign prostatic hyperplasia (BPH), coronary artery disease, hearing loss, permanent pacemaker, osteoarthritis, hyperlipidemia, and urinary incontinence who had been assigned PCA (personal care assistance) services based on telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer toilet while independent with tasks of bed mobility and eating. 

Personal Care Assistance Services: 56 hours per week are medically necessary for this patient. 

The patient was recently hospitalized with subsequent rehabilitation stay and the patient's assessment documents an increased need in assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, bed mobility, and eating. It was assumed that the patient has informal help outside of the currently approved PCA services. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). 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 56 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 his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions.[1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay.[2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting.[3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible.[5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes.[6]

Per clinical documentation, this patient presented to the ED (emergency department) with a one-day history of acute right upper quadrant abdominal pain. There was associated nausea without vomiting. Vital signs in the ED were within normal limits. The patient had a CT (computed tomography) scan that demonstrated cholelithiasis without evidence of cholecystitis. White blood cell count was slightly elevated at 11.7. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. Per MCG (Milliman Care Guidelines) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for an inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be billed as observation status. Inpatient admission is not medically necessary. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Gastroesophageal Reflux Disease (GERD)

Treatment: LINX procedure

The insurer denied coverage for LINX procedure

The denial is overturned

This case involves a male diagnosed with GERD. The patient was seen regarding GERD. Work-up included a pH (potential of hydrogen) test which revealed a DeMeester score of 71. Endoscopy showed no evidence of malignancy. Erosive esophagitis was seen. Esophagram showed severe reflux in the level of the clavicles. There was a tiny hiatal hernia. Manometry read as normal esophageal motility with 92% (percent) of the swallows complete bolus clearance. On examination, the abdomen was flat and bowel sounds were normal. The patient was recommended for LINX procedure.

According to a letter, the patient had a long history of GERD. The patient had been treated with daily acid suppressing medication. The medications did not provide complete relief. The patient was recommended for the LINX procedure.

The patient has refractory GERD unresponsive to PPI (Proton Pump Inhibitor) therapy. 24-hour pH monitoring revealed persistent reflux as evidenced by high DeMeester score. He needs a procedure to treat reflux. Given that he has minimal to no hiatal hernia, the requested treatment would be preferred. As such, the requested procedure is appropriate. 

The LINX Reflux Management System has been shown in the scientific peer reviewed literature to result in improvement in health outcomes. It has approval from the FDA (Food and Drug Administration). The patient is a good candidate for the procedure. There are several procedures available for the treatment of GERD, but the LINX procedure has been shown to be safe and effective. The patient has had an extensive workup for GERD and appears to be a good candidate for this procedure.

The requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient. 

The carrier's denial of the LINX procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Gastroesophageal Reflux Disease (GERD)

Treatment: LINX procedure

The insurer denied coverage for LINX procedure

The denial is overturned

The patient has a history of chronic GERD. An endoscopy showed erosive gastritis. A tiny hiatal hernia was reported. An upper gastrointestinal (GI) series documented significant reflux. Potential of hydrogen (pH) testing showed a DeMeester score of 71. Manometry revealed normal esophageal motility.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the LINX Reflux Management System. With regards to safety, the conclusion was that long term follow-up supports the FDA (Food and Drug Administration) conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH normalization, improved quality of life, and cessation of regular proton pump inhibitors (PPI) use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following LINX. The long-term follow-up data demonstrates that the LINX Reflux Management System is effective in the management of GERD.

The LINX Reflux Management System has been shown in the scientific peer reviewed literature to result in improvement in health outcomes. It has approval from the FDA. He is a good candidate because he has a long history of continued GERD symptoms. There are several procedures available for the treatment of GERD, but the LINX procedure has been shown to be safe and effective. The patient has had an extensive workup for GERD and appears to be a good candidate for this procedure.

The requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient.

The carrier's denial of the LINX procedure should be overturned.