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

Diagnosis: Chest Pain
Treatment: Inpatient admission

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

This male was hospitalized chest pain and elevated blood pressure. He presented to the hospital emergency department for evaluation of chest pain since the prior week and elevated blood pressure readings. The clinical impression was possible acute coronary syndrome (ACS) and hypertensive urgency. His past medical history is pertinent for hyperlipidemia (HLP). He was pain free and vital signs revealed his blood pressure was 180/100, The patient's s heart rate was 98, respiratory rate (RR) was 18 and oxygen saturation (O2 sat) was 100% on room air. Follow up blood pressure was 144/102. The patient's electrocardiogram (EKG) was normal. There were no arrhythmias or elevated troponin documented. The patient's lipoprotein (LDL) was elevated to 166. His chest x-ray was negative. The treatment included aspirin (asa) and statin. He did not want to stay over the weekend to have a cardiac catheterization and requested to go home. The patient was advised to follow up with cardiology for one week. 

This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

No, the proposed inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The care the patient received is routinely provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tardive dyskinesia
Treatment is Ingrezza 40 mg oral capsules
The insurer denied coverage for Ingrezza 40 mg oral capsules
 The denial is upheld

This case involves a patient with a document noting the patient's medical history of anxiety disorder, asthma, tobacco abuse, insomnia, asthma, and a dysthymic disorder.  She had a family history of Parkinson's in her father, and it was noted at the time of her visit that she endorsed abnormal involuntary movements to include restless legs of a moderate degree. At the time of the visit, the physician was refilling lorazepam tablets and starting the patient on valbenazine capsules at 40 mg (milligrams), 1 capsule orally each day for 1 week and then 2/day for 30 days. The records reference to prior medications consisting of Lexapro, zolpidem, olanzapine, and a third dose of lorazepam. The patient received a final adverse determination denial notice pertaining to Ingrezza 40 mg oral capsules stating that the medication is indicated for treatment of tardive dyskinesia (a disorder that results in involuntary body movements). The criteria for use of the medication were not met as the patient had not taken or had a poor response to medications on the preferred drug list to include tetrabenazine (Xenazine). This review pertains to denial of coverage for Ingrezza.

The Food and Drug Administration states that Ingrezza is indicated for the treatment of adults with tardive dyskinesia. Records indicated the patient had a history of abnormal involuntary movements (AIMS) to include restless legs.  Records indicated the patient's neurologist had recommended use of Ingrezza for dyskinesia. However, the patient had no documented history of a poor response to medications on the preferred drug list with claims that the treating physician should consider tetrabenazine. There were no exceptional factors or extenuating circumstances identified within the records to justify use of Ingrezza over the preferred medication. Up to Date does not note any strong preference between the two drugs noting a lack of direct comparison. Therefore, the prior determination is upheld. The request for Ingrezza 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 Ingrezza is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal congestion, urinary tract infection, decreased activity
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an infant with a history of nasal congestion, a known urinary tract infection (UTI) treated with Keflex, and a decrease in activity. The patient had one loose stool. The patient did not have any concern for difficulty breathing or fever. There is no notation of a decrease in urine output.

Yes, the proposed inpatient hospital admission was medically necessary.

The patient was noted to have a decrease in oxygenation, decreased oral intake (PO), and signs of respiratory distress. As per the signs of respiratory distress and dehydration noted on the exam, it is not medically appropriate for the patient to be discharged home by comparison. The patient required close monitoring and inpatient care via oxygen, intravenous fluids and close monitoring of vitals. The patient had emesis, demonstrating difficulty in tolerating PO.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The denial was not appropriate as the patient required close monitoring and further care by trained medical professionals.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia

Treatment: 7 days per week, 24 hours per day (live-in) personal care assistance services

The insurer denied coverage for 7 days per week, 24 hours per day (live-in) personal care assistance services.

The denial is overturned.

This is a patient with chronic medical problems including Alzheimer's dementia. She lives with her daughter and granddaughter. The daughter works and cannot continue to provide care. The grandchildren are not involved. She is currently approved for personal care assistance (PCA) services 68 hours/week. Currently under review is the request for increase PCA services 7 days/week, 24 hours/day (live-in). 

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as severely impaired. She requires maximal assistance for bathing, personal hygiene, dressing, walking and toilet use. She is frequently bladder and bowel incontinent. This has become more severe as her dementia progresses. Extensive assistance is needed for eating, toilet transfers and walking. A letter by her care manager noted that there has been significant deterioration. She has been found half of her body in the bed and unable to pull herself back into position. Also, noted that pullups need changing at least every 2 hours. The patient uses diuretics which increases urination. She has also had fungal infections in her groin area. The UAS notes the daughter was instructed in the importance of repositioning every 2 hours and change incontinence supplies on time. The patient has severe cognitive deficits and significant functional impairments, which continue to decline and support the medical necessity of increasing PCA services to 7 days per week, 24 hours per day (live-in)

Her condition and functional needs are at a level or unpredictable, as to require the requested 24 hours per day (live-in) PCA services.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, the requested PCA service 7 days/week, 24 hours/day (live-in) is medically necessary.  

The insurer's denial of coverage for 7 days per week, 24 hours per day (live-in) personal care assistance services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: General debility and deconditioning status post cerebrovascular disease
Treatment: Continued Stay in Skilled Nursing Facility at Alternate Level of Care (Short-Term Custodial) 
The insurer denied the continued stay in skilled nursing facility at alternate level of care (short-term custodial). 
The denial is overturned.

The patient is an adult female with a history of general debility and deconditioning status post cerebrovascular disease with receptive aphasia, right hemiparesis, history of chronic obstructive pulmonary disease (COPD), and seizures. She has been in long-term custodial care but with increasing debility and requiring more assistance for transferring from bed to wheelchair, instability when standing, decreased strength, and increased risk of falls.

The patient's prior level of functioning while a resident of long-term custodial care was requirement of supervision for transfers, ambulate 100 feet, using quad-cane and wheelchair.

As of approximately one month ago, the patient had poor dynamic standing, she required supervision for transfers, she was able to ambulate 50 feet using quad-cane with contact-guard, she required moderate-maximum assistance with upper/lower body dressings, and total dependence with toileting, et cetera (and the rest).

The proposed treatment is medically necessary.

The continued stay in the skilled nursing facility rehabilitation is medically necessary because the patient developed general debility and deconditioning that led to the patient requiring more assistance for transferring from bed to wheelchair, instability when standing, decreased strength, and increased risk of falls.

The patient had poor dynamic standing, required supervision for transfers, was able to ambulate 50 feet using quad-cane with contact-guard, required moderate-maximum assistance with upper/lower body dressings, and was total dependence with toileting, et cetera.

In view of this, it was medically necessary for the patient to undergo more intensive rehabilitation as she is also a high risk for falls and she was deteriorating to the extent that a more intensive rehabilitation was necessary.

A four-week period of intensive rehabilitation is recommended before the patient's status is re-evaluated for continued medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol intoxication
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male with medical history of alcohol abuse and remote tuberculosis. He presented to the emergency department with alcohol intoxication. He had multiple drinks and thinks that he fell. He had coffee-ground emesis after presentation. Vital signs were notable for pulse rate of 99/minute. Physical examination was notable for tachycardia and disorientation. Labs showed unremarkable complete blood count, elevated glucose of 376 , elevated blood alcohol level of 227, lipase of 65, low venous blood gas potential hydrogen (pH) of 7.28, elevated bicarbonate of 50.3, low partial pressure of oxygen (PO2) of 30, elevated lactic acid of 4.9, and low oxygen saturation of 44%. He was treated with intravenous fluids and pantoprazole.

The inpatient hospital admission was not medically necessary. The patient had an elevated blood glucose but did not have a diagnosis of diabetic ketoacidosis or hyperosmolar hyperglycemic state. He was noted to be intoxicated on presentation, but did not have alcohol withdrawal during his stay. He had coffee-ground emesis in the emergency department, suspected to be due to erosive or peptic ulcer disease versus Mallory-Weiss tear, but did not have ongoing bleeding, or sustained tachycardia or hypotension; his hemoglobin remained stable. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Proton pump inhibitor therapy was appropriately initiated. Gastroenterology did not perform an esophagogastroduodenoscopy. All of the measures that were undertaken, including monitoring, labs, proton pump inhibitor therapy, treatment of diabetes mellitus, and specialist consultations, could have been performed in sequence after presentation at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough
Treatment: Emergency room visit
The insurer denied the emergency room visit. The health plan's determination is upheld. 

The patient is a male who presented to the Emergency Department with the complaint of cough. He reported having a chronic dry cough over the last 10 to 11 months, that was gradually worsening over the past 6 weeks. He was sick with COVID-19, but the cough started before that. He denied any fever, chest pain, difficulty breathing, or hemoptysis. He had seen a pulmonologist the month before and was instructed to use a proton pump inhibitor and montelukast, but had no improvement in his symptoms. He was going to see an allergy specialist in 5 days for possible cough variant asthma. He was scheduled to have a chest x-ray the next week, but was coughing "nonstop" and felt he could not wait until then to be seen. He denied smoking, vaping, or drug use. His review of systems was otherwise negative. His vital signs were unremarkable except for an elevated blood pressure of 141/87. His physical exam was unremarkable. A 1-view chest x-ray was performed and unremarkable. He was discharged in stable condition with the diagnosis of chronic cough with instructions to try using an albuterol inhaler and follow up with the specialist as planned.

The Emergency Department visit was not medically necessary for this patient. The patient presented with 10-11 months of cough, that was gradually worsening over the last 6 weeks. He was already under the care of a specialist and had close follow up with another specialist. He denied any shortness of breath, chest pain, hemoptysis, or fevers that would suggest a life-threatening condition. His vitals and physical exam were unremarkable. There was nothing in the documentation that suggested he or the physician felt he was having a life-threatening Emergency Condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carcinoma of the tongue
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult female with carcinoma of the tongue. The plan for therapy was chemotherapy, radiation and neck dissection. The patient had neck dissection and was discharged two days later. The patient had Jackson-Pratt (JP) drains which are reported to have been removed on the date of discharge. The patient insisted she did not want to go home on post-operative day (POD) #1 because of drains. The patient had an uncomplicated operative and postoperative course. Surgery took two and a half hours. Her post vital signs included blood pressure (BP) 127/62, heart rate 54, temperature 97.4, respiratory rate 15 and oxygen saturation (SP02) 99%.

The proposed inpatient hospital admission was not medically necessary.
Medical necessity for acute inpatient care was not established. The patient was ready for discharge on post-operative day (POD) #1 and stayed for convenience as she insisted on staying because of her drains. From the record, the drains could have been removed as an outpatient. The patient had an otherwise uncomplicated course and could have been managed at a lower level of intensity than acute inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is overturned.

The patient has a past medical history notable for tobacco use, hypertension, medication noncompliance, chronic obstructive pulmonary disorder (COPD), depression, anxiety, and substance abuse. He presented to the emergency room (ER) with chest pain associated with bilateral arm weakness and paresthesia for the prior 3 days. His pain was noted both at rest and on exertion. Vital signs noted initial hypertension with subsequent normotension. The exam in ER by the attending noted rales and wheezing bilaterally. BNP (B-type natriuretic peptide) was elevated at 2095, while troponin was negative. A chest radiography showed interstitial edema. A CTA (computerized tomography scan) of the chest noted ground-glass haziness and findings consistent with pulmonary edema. He was given intravenous diuretics and antihypertensive therapy. He ruled out for myocardial infarction. An echocardiogram noted a left ventricular ejection fraction of 15%. He continued to receive intravenous diuretics, and his scheduled cardiac catheterization was cancelled due to a rise in serum creatinine to 1.7. He subsequently left the hospital against medical advice.

The patient presented with complaints of chest pain and congestive heart failure. He was noted to have clinical and imaging findings indicative of acute pulmonary edema. This justified the admission. 

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 inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ankle fracture.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission. 
 The denial is upheld.

This is a female patient with a history of a left ankle fracture, right ankle sprain, hypertension, kidney transplant, hyperlipidemia, vertigo, and gastroesophageal reflux disease (GERD). She presented to the hospital for a left ankle open reduction internal fixation (ORIF). The insurer has denied coverage for the inpatient admission, as not medically necessary. In a Final Adverse Determination letter they stated that the patient was admitted to the hospital after surgery to fix broken bones in the ankle. There were no problems with the procedure. The requested service is denied based on Milliman Care Guidelines 25th Edition using the guideline of Ambulatory Surgery Exception Criteria. 

In an appeal letter it stated that the patient had a left ankle fracture and right ankle sprain. She underwent a left ankle ORIF during the admission. After surgery, she was admitted for care. Intravenous (IV) antibiotics were given, and home medications were continued. Labs were monitored. She was seen by PT (physical therapy). The requested admission was warranted based on Milliman Care Guidelines 25th Edition using the guideline of Ankle Fracture, Closed, Open Reduction and Internal Fixation. 

The medical record showed a non-complicated surgical procedure. The operation process is about 4 hours. There were no problems with anesthesia. The post-surgical course showed satisfactory pain control and ability to tolerate oral medications. Her vital signs were stable. There was no evidence of bleeding nor temperature. Taking into consideration, the previous kidney transplant, creatinine remained below 1. Physical therapy (PT) services were initiated. She was able to be mobilized and ambulated non weight bearing 25 feet. The physical therapy department discharged her and recommended home treatments. The only recommendation for additional service was made for a wheelchair. 

There were no medical problems to require ongoing length of stay. There were no additional services required which would include consultations, imaging, medications, and consideration of her elevated BMI (body mass index) and elevated WBC (white blood cell count) to 15. 

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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain.
Treatment is an inpatient admission. 
The insurer denied coverage for an inpatient admission. 
 The denial is overturned.

The patient presented with abdominal pain. He was febrile to 101 degrees F (Fahrenheit) and tachycardic with a pulse of 140 in the emergency room (ER). Severe tenderness with involuntary guarding was present. The gastroenterology consults states that the patient had both rebound and guarding. The WBC (white blood cell count) count was 10.95. A CT (computed tomography) scan was read as sigmoid diverticulitis with a small focus of free air as well as fluid suggestive of a perforation. The patient was kept nothing per mouth (NPO) and given IV (intravenous) antibiotics. 

Clinical indications for admission for Acute Diverticulitis (MCG M-150) include having peritoneal signs such as severe abdominal tenderness and rebound or involuntary guarding. A free perforation is also an indication for admission. This patient had evidence of peritoneal signs. He had a complicated diverticulitis with a perforation and possible abscess. He required being kept NPO and receiving IV antibiotics.

The patient had a complicated acute diverticulitis with peritoneal signs, fevers,
and extraluminal air and fluid. He met the MCG (Milliman Care Guidelines) criteria for admission for Acute Diverticulitis. 

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 inpatient hospital services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment is a stress echocardiogram
The insurer denied coverage for a stress echocardiogram
The denial is overturned

This is a patient with a history of hypertension, hyperlipidemia and amaurosis fugax. The patient presented to his cardiologist complaining of chest pain and dyspnea on exertion. His family was significant for coronary disease in his mother and brother. 

Stress echocardiography is medically necessary in this case. According to the medical records, this patient had typical angina symptoms, a history of amaurosis fugax and a strong family history of coronary artery disease. His pretest probability of significant coronary disease is intermediate. AHA (American Heart Association) /ACC (American College of Cardiology) /ASE (American Society of Echocardiography) guidelines recommend noninvasive testing for such patients. (Reference 1). Appropriate use criteria deem stress echocardiography to be an appropriate diagnostic test for such patients. (Reference 2). In conclusion, stress echocardiography was medically necessary in this patient.

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 a stress echocardiogram is overturned. Medical Necessity is substantiated.