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

Diagnosis: Nausea and vomiting
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of polycystic ovary syndrome (PCOS), gastric sleeve, generalized anxiety disorder (GAD), major depressive disorder (MDD), and ethanol abuse who was admitted with complaints of (c/o) nausea and vomiting. The vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD) and normal abdominal examination. Lab work was notable for mild leukocytosis. A computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology. The patient was diagnosed with gastritis and treated with a proton pump inhibitor (PPI) and anti-emetics. Bariatric surgery evaluated the patient and determined no acute interventions were needed. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) nausea and vomiting. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. Bariatric surgery evaluated the patient and determined there was no need for acute surgical intervention, and the patient was ultimately diagnosed with gastritis. The patient presented with nausea and vomiting without an acute surgical abdomen, was treated and responded to intravenous fluids (IVF), a proton pump inhibitor (PPI), and anti-emetics, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: back pain
Treatment: Ablative Treatment for Spinal Pain 
The insurer denied Ablative Treatment for Spinal Pain 
The health plan's determination is overturned. 

This patient is a female who has chronic low back pain. She had previously tried extensive treatments including physical therapy, chiropractic manipulation, sacroiliac (SI) joint injection, lumbar medial branch nerve blocks, epidural injections and radiofrequency ablation. Her other treatments included anti-inflammatory medications and a home exercise program. She has worsening of her lower back pain over time. Her pain is debilitating and interferes with her activities of daily living.

Ablative Treatment for Spinal Pain is medically necessary for this patient.
This patient has persistent debilitating back pain with a negative impact on her activities of daily living (ADL) and quality of life. Further treatments are medically necessary to improve her pain and function.
The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrated the sustained improvements in pain and function from this intervention for patients with vertebrogenic pain. This patient had failed extensive treatments including physical therapy (PT), lumbar epidural injections and a sacroiliac joint injection. Her pain is severe enough with a negative impact on her ADLs. Further interventions are medically necessary to improve her pain and function. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the requested procedure is medically necessary as the next step intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Stay

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

The male patient admitted for a diagnosis of tachycardia and cellulitis of the right lower extremity, presented with a chief complaint of right knee pain. He presented after being burned on the knee by a cigarette, which occurred one week before admission. Vital signs demonstrated blood pressure 104/74, pulse 95, temperature 100 (degrees) Fahrenheit (F), respiratory rate 18, and oxygen saturation(O2) 98 percent (%). 

The inpatient hospital admission was not medically necessary. 

In this case, the patient was admitted for cellulitis but had no soft tissue red flag condition requiring hospitalization. He did not have toxic shock syndrome, necrotizing fasciitis, joint involvement, involvement of a vascular graft, pyomyositis, gas gangrene, or compartment syndrome. There was no severe sepsis or septic shock. There was no rapidly progressive infection or pain out of proportion to the exam findings. He did not have a fever greater than 100.5F or sustained tachycardia. There was no extensive erythema or an immunocompromising condition such as neutropenia or chemotherapy. There was no hemodynamic instability.

Although the patient required services in the hospital setting, the monitoring, diagnostic testing, and therapeutic interventions could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week
The insurer denied Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week
The health plan's determination is overturned. 

The patient is a female with a past medical history of coronary artery disease, osteoarthritis, hypertension, history of gastrointestinal (GI) bleeding, glaucoma, cataracts, atrial fibrillation, and urinary incontinence whose family requested an increase in PCS (personal care services). 

Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCS services. The patient lives alone and has no informal help outside of the currently assigned PCS service hours. The assessment documented the patient requires maximum assistance with transfer toilet and toilet use which are 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 plan suggested the patient reduce her intake of fluids after 6 PM which certainly would not be recommended in a patient on diuretic therapy who needs to drink water when thirsty. 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, the requested PCS services 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: Upheld

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

The patient is a female who was admitted for the diagnosis of multifocal pneumonia. The patient presented with chief complaint of hypoxia, tachycardia and hypotension. She was previously seen in the emergency room (ER) and noted to have six days of fever, chills, and cough with one episode of emesis. She had been treated with three days of oral Levaquin at urgent care without improvement. At the time of this admission, she denied fever, shortness of breath, chest pain, palpitations, leg edema, or sputum. She had dry cough which was improving. Vital signs demonstrated temperature 99.9 degrees Fahrenheit, pulse 104, respiratory rate 20, blood pressure 109/69, and O2 (oxygen) saturation 91% (percent) on room air. Physical exam showed no acute distress or altered mental status. 

The inpatient hospital stay was not medically necessary. 

The patient in this case required previous admission for treatment of pneumonia. She was then discharged with a home program and then was thought to have hypotension, tachycardia, and hypoxia and so she was sent back to the emergency department. At the time of ER presentation she had O2 saturation above 90% and also throughout the hospitalization. Blood pressure was preserved at 109/69. She had a pneumonia severity index calculation showing risk class 2 with a 0.6 to 0.9% mortality. This is usually acceptable for a lower level of care. She had evaluation with a computed tomography (CT) angiogram which excluded pulmonary embolism as a contributing factor. The study also showed improving multifocal pneumonia. 

Although the patient required services in the hospital setting, the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis and Acute Kidney Injury. 
Treatment: Inpatient Hospital Stay.

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

The patient is a male with a history of hypertension, atrial fibrillation, and cardiomyopathy, who presented to the emergency department (ED) for right leg swelling and pain. The review of systems was negative for additional symptoms.
The patient was afebrile. He was in no apparent distress. His vital signs were stable on admission. The physical examination was remarkable for swollen, redness and tenderness right leg up to below the knee level.
Laboratory evaluation demonstrated a leukocytosis of 12.6 and the chemistry was remarkable for blood urea nitrogen (BUN) /creatinine of 39/2.25.
The patient was admitted for right lower extremity cellulitis and acute kidney injury (AKI) on chronic kidney disease (CKD). A prior echocardiogram showed an ejection fraction (EF) of 45-50 percent (%). An ultrasound (US) of the lower extremity was negative for thrombosis. The patient was treated with intravenous (IV) antibiotics. The patient's baseline creatinine was reported as 1.2. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was medically necessary.
Based on the documentation provided, the patient was admitted to an acute inpatient level of care for acute kidney injury in the setting of underlying kidney disease. Inpatient level of care was necessary for rapid correction of renal function in the setting of underlying heart failure.
Acute kidney Injury (AKI) is defined by an increase in serum creatinine of 0.3 milligrams per deciliter (mg/dl) within 48 hours. In addition to an AKI, the patient also has underlying chronic kidney disease (CKD) which is a clear risk factor for AKI and worsened outcomes. AKI is shown to accelerate the progression of CKD and can result in the need for dialysis and is associated with worsened long-term renal outcomes. In this case, the patient was admitted for severe hyperkalemia in a setting of a declining glomerular filtration rate and worsened renal insufficiency. Therefore, the patient was at risk for long term worsened outcomes. This warranted urgent treatment to prevent the deleterious effects of hyperkalemia. Furthermore, the mortality risk is progressively increased in patients with hyperkalemia who also have underlying chronic kidney disease, diabetes, and congestive heart failure. The in-hospital mortality rate was 18 percent (%) as compared to 4% for patients with normal potassium levels.
CHF patients with AKI require attentive management of fluid and electrolyte status to promptly reverse fluid deficits in preventing further exacerbation of the AKI. Once fluid deficits have been corrected, patients must be carefully assessed to ensure that the patient does not develop excessive volume expansion that may lead to pulmonary edema, a common complication. The patient presented with AKI by definition and required intravenous hydration and close monitoring for complications given his underlying CHF.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: Braces and Monthly Visits.

The insurer denied coverage for braces and monthly visits. The denial is upheld. 

Upon review of the submitted documentation, including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings, including overjet, overbite, and anterior crowding, and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 30 points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining 13 points by internal reviewers. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess the severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation Index. 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 does not claim an automatic qualifying condition and completes the second portion of the index, arriving at 30 points to justify orthodontic care. This reviewer concurs with the index conducted by the insurer, attaining a total of 13 points on the HLD index (5 overjet, 6 overbite, 2 labiolingual spread), which is below the threshold of 26 points to support orthodontic care. 

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 needs is valid. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, it has been determined to represent an appropriate approach for assessing orthodontic needs.

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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

The medical necessity for braces and monthly visits is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Promyelocytic leukemia

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital.

The denial is overturned.

 
According to the medical records, the patient is an adult male with acute promyelocytic leukemia. He was treated with all-trans retinoic acid (ATRA) and developed Differentiation Syndrome, and was transferred to another hospital with a higher level of Hematology support. He was hospitalized for 31 days to complete treatment.

It is clear that the patient was very ill with the very serious complication of D-differentiation Syndrome. Differentiation Syndrome is a complication of all-trans retinoic acid (ATRA) therapy in patients with acute promyelocytic leukemia (APML). It appears clinically as acute end-organ damage with peripheral edema, hypotension, acute renal failure, and interstitial pulmonary infiltrates.

"Differentiation Syndrome is a complication of all-trans retinoic acid (ATRA) therapy in patients with acute promyelocytic leukemia (APML). It appears clinically as acute end-organ damage with peripheral edema, hypotension, acute renal failure, and interstitial pulmonary infiltrates. When symptoms develop, physicians are recommended to stop ATRA therapy to minimize complications and reduce mortality immediately. This case report describes a patient who was diagnosed with acute promyelocytic leukemia after he developed episodes of hematuria and easy bruising at home. After beginning a treatment regime of ATRA, steroids, and arsenic, the patient began to have symptoms of differentiation syndrome." (Reyhanoglu, G. et al. 2020).

The insurer denied transfer and inpatient stay at the Hospital stating that the request could only be approved when certain criteria are met 1) the person needs treatment not available at the current hospital; 2) the person needs to be seen by a specialist not available timely at the current hospital; 3) the person has received care/treatment at a certain hospital that is not available at the current hospital. 

Evaluation of the originally submitted case files showed that there was not sufficient oncology/hematology specialist staffing in place at the first Hospital to handle the increased management requirements of the patient's complex condition. Thus, in this clinical scenario a transfer would have been appropriate, medically necessary, and would meet the insurers criteria for transfer for oncology/hematology specialist services.

Therefore, the reviewer must overturn the insurer's determination. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The medical necessity for an inpatient stay at the Hospital is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with end stage renal disease status post kidney transplant who was admitted for a kidney biopsy. Post biopsy he was noted to have a hematoma and was monitored for signs of bleeding. His blood count remained stable with a normal blood pressure and he was discharged. At issue is the medical necessity of inpatient admission.
An inpatient hospital admission was not medically necessary. The patient could have been treated safely under a lower level of care. A kidney biopsy can be done safely as an outpatient and does not require inpatient admission. The patient, post kidney biopsy, was noted to have a renal hematoma, however; he remained hemodynamically stable, with a stable hemoglobin, did not have significant hematuria, and did not require bladder irrigation. When taking into account the patient's exam, imaging, and lab findings, as well as his lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, he had no requirements for an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the emergency department (ED) with substernal chest pain for the past 3 days. The patient described the chest discomfort as a heavy sensation in the middle of her chest. According to a different note, her chest pain was more localized towards right side below clavicle. It was aggravated on walking, with no radiation.
The patient has a history of asthma, hypertension (HTN), pre-eclampsia, left lower extremity (LLE) deep vein thrombosis (DVT), and pulmonary embolism (PE). She is currently on Eliquis. She also is taking hydrochlorothiazide for blood pressure (BP). The patient also had back pain.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with chest pain, which had some atypical features. The patient had coronary risk factors of hypertension. The patient's electrocardiogram (ECG), and troponin were normal. She did not have any evidence of acute coronary syndrome.
The patient recently was diagnosed with DVT/PE and was on anticoagulation. The patient did not want to undergo another computed tomography angiography (CTA) because she had 2 of them recently. Her vital signs were normal.
Her D-Dimer and brain (or B-type) natriuretic peptide (BNP) were normal. Her echo did not reveal elevated PA (pulmonary artery) pressure or right ventricle (RV) strain. Based on the above, the patient did not have indications for inpatient admission for recurrent PE. The patient was admitted for observation. Her condition was more appropriate for a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bleeding in the Stomach
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is overturned.

The patient is an adult female. She presented to the emergency department with blood in her stool three times per day. She stated she had melanotic stool for four days. She had a history of non-steroidal anti-inflammatory drug (NSAID) use, felt weak, nausea, poor oral intake, and mild dyspnea with exercise. She had a history of Roux-en-Y gastric bypass, hypertension, gastrointestinal bleed, nausea, and history of narcotic addiction and alcohol addiction.  Labs showed an elevated blood urea nitrogen (BUN) of 40.3, elevated creatinine of 1.87, elevated potassium of 5.2, CO2 (carbon dioxide) of 13, anion gap of 33, hemoglobin of 11.8, aspartate transaminase (AST) of 87, alanine aminotransferase (ALT) of 41, and alkaline phosphatase of 142.
The patient presented and was discharged on day number (#)6. On day #2, hemoglobin was 10, aspartate transaminase was 95, blood urea nitrogen was 23, and creatinine was 0.95. Blood pressure was high at 180/109. Gastrointestinal was consulted and 
esophagogastroduodenoscopy (EGD) showed a large clean based anastomotic ulcer. Gastrointestinal recommended intravenous proton pump inhibitors twice a day (bid) for 24 hours, then by mouth at 40 milligrams bid (twice daily) and Carafate 1 gram four times daily. On day #3, the patient reported lower abdominal / pelvic pain. Aspartate transaminase was 133 and blood pressure was 187/112. A computed tomography (CT) scan showed no pathology explaining the lower abdominal pain. Diet was advanced. She was restarted on Valsartan and the dose was increased to 160 milligrams twice daily. On day #4, the patient reported lower abdominal discomfort. Aspartate transaminase was 177, and alanine aminotransferase was 69. She received intravenous morphine times (x) 3 for 7/10 pain, intravenous hydralazine 10 milligrams every six weeks (received x 1), amlodipine was increased from 5 milligrams to 10 milligrams per day, and oral hydralazine was started at 2.5 milligrams by mouth three times a day. On day number (#) 5, the patient's aspartate transaminase was 171, alanine aminotransferase was 79. Blood pressure was 185/112. The patient had continued abdominal pain and received morphine times (x) 3. The patient had chest pain. Electrocardiogram (EKG) was normal. Troponin was negative. On day #6, she was tolerating a diet. She was discharged home.

The Inpatient admission was medically necessary.

The patient required an inpatient level of care for managing pain requiring intravenous pain medications (morphine) to control the pain. Additionally, the patient had uncontrolled hypertension requiring blood pressure control with intravenous anti-hypertensives (hydralazine) and adjustment of her oral anti-hypertensive regimen. Therefore, the requested health service is medically necessary.