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

Diagnosis: fever and vomiting

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This patient is an infant who was born full term and emigrated 2 months prior but had no past history of illness or underlying conditions. The patient was presented with fever for 3 days and no other symptoms except for one emesis episode and was behaving normally when afebrile. Per history obtained vis translator, it is documented the patient had been drinking well and wetting 3 diapers a day as per baseline. The review of systems was otherwise negative.

On exam the patient had a temperature of 99.8 degrees Fahrenheit (F) with a heart rate of 161 beats per minute and normal blood pressure (BP), appearing nontoxic, active, not in acute distress. The patient was assessed as having mild to moderate dehydration. Systems exam was normal. 

The patient's labs revealed large leukocytes on urinalysis, a bicarbonate level of 11 (low), c-reactive protein (CRP) that was mildly elevated at 3.9, white blood cell (WBC) count elevated at 25.6, and platelets of 495 (elevated).

A decision was made to admit and administer intravenous (IV) antibiotics, but the record is lacking in any Medical Decision Making to support this plan of management. 

Despite arriving with 104.4 degrees Fahrenheit fever, the patient was afebrile when assessed by the emergency department (ED) provider 1 hour later.  After discussion with Infectious Disease (ID), their suspicion of malaria was deemed low, for which it was decided liver functions would be assessed but malaria smears do not appear to have been ordered.

Continuous intravenous antibiotics were not indicated at first. There was no evidence of acute kidney injury (AKI), liver inflammation, hemolysis or sepsis syndrome. The elevated white blood cell (WBC) count and platelets were attributable to the presumed urinary tract infection (UTI). 

"Most children older than two months with UTI who are not vomiting can be safely managed as outpatients as long as close follow-up is possible" [Shaikh, N and others (et al.)]. The referenced article clearly delineates the usual indications for hospitalization as any of the following: 
Age under 2 months, clinically apparent urosepsis (such as toxic appearance, hypotension, poor capillary refill), immunocompromised febrile patients, vomiting or inability to tolerate oral medication, lack of adequate outpatient follow-up, or failure to respond to outpatient therapy. None of these apply in this case.

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

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: congestion/fever
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is an infant who presented with cough, congestion, and fever. She was well until 3-4 days prior to presentation when she developed congestion and fever. On the day prior to presentation, she developed belly breathing and fast breathing. Her temperature was up to 103.1oF at home. She continued to breathe fast, and therefore was brought to the emergency department for evaluation.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young infant who presented with bronchiolitis who had respiratory distress and hypoxemia. She required hospital admission for administration of supplemental oxygen, frequent saline nebulized treatments, and intravenous fluids to maintain her hydration status along with continuous monitoring with additional treatment as needed.
Hospitalizations indicated for infants and young children with bronchiolitis who have moderate respiratory distress, manifested by retractions and tachypnea, and for those with hypoxemia who require supplemental oxygen. The decision making at the time of admission for this patient was consistent with her young age, the presence of respiratory distress, fever, and hypoxemia, and the need for intensive treatments including supplemental oxygen and intravenous fluids along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: febrile seizure
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned.

The patient is a 1 year old boy who presented after a first time febrile seizure. He was well until 2 weeks prior to presentation when he developed a cough. On the night prior to presentation, he developed a fever to 101.5oF. He received ibuprofen, but continued to have fevers. Soon after he fell asleep the next day, he started shaking with his eyes moving upward and he started turning blue in the face. The movements lasted 5-7 minutes. Emergency services were called, and upon their arrival administered oxygen due to persistent cyanosis.

Inpatient Hospital Admission was medically necessary for this patient. He required hospitalization in order to administered needed parenteral treatments as well as for close monitoring.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines,26th edition, Seizure, Pediatric; hospitalization is indicated for patients with febrile seizures who have an etiology that requires monitoring or intervention at an inpatient level of care.
This patient had a febrile seizure with cyanosis, and was found to have fever and an elevated white blood count with left shift as well as x-ray findings consistent with multilobar pneumonia. He therefore required hospital admission for prompt initiation of parenteral antibiotics to treat a potentially serious infection, along with close monitoring with additional treatments as needed. In the hospital, he continued to have fevers and irritability, and required ongoing care until his symptoms improved.
The decision making at the time of admission for this patient was consistent with his young age, the occurrence of a febrile seizure with continued fever and elevated inflammatory markers, and the need for prompt treatment with parenteral antibiotics while culture were pending, along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: knee osteoarthritis, hypertension, dizziness and giddiness, incontinence for bladder and bowel

Treatment: Personal Care Aide (PCA) services, Live-In, 24 hours per day, 7 days per week

The insurer denied coverage for Personal Care Aide (PCA) services, Live-In, 24 hours per day, 7 days per week

The denial is upheld

 
This case pertains to an elderly male who lives in a house with his adult son. He is diagnosed with bilateral knee osteoarthritis, hypertension, dizziness and giddiness, incontinence for bladder and bowel, gastroesophageal reflux disease, hyperlipidemia, insomnia, legally blind, lower back pain, noninfective gastroenteritis and colitis, anxiety and depression, polyneuropathy, seborrheic dermatitis, type 2 diabetes, macular degeneration, and unsteadiness. His medications include Balsalazide, cannabidiol gummy, Colazal, Crestor, Escitalopram, Gabapentin, Imodium, Meloxicam, Metformin, Omeprazole, Ramipril, Rosuvastatin, Sertraline, and Tylenol.

He is minimally impaired cognitively in specific situations regarding poor decision making. He is frequently incontinent for bladder and bowel. Physical therapy notes he has improved in his sit to stand and walking requiring minimal assistance. He is totally dependent for housekeeping, shopping, and meal preparation. He requires maximal assistance with bathing, dressing, personal hygiene, and toileting. He requires extensive assistance with eating. 

The Aide Tasking tool assessed the need for 54 hours and 24 minutes per week of personal care aide assistance. The plan re-evaluated his care and awarded 11 hours per day 7 days per week. He will receive 77 hours per week of personal care aide (PCA) services. There is no indication that he wanders or gets up at night. The plan recommended a personal emergency response system, a referral to the visions program. He has a walker, a rolling walker, grab bars, urinal, depends diapers and a wheelchair. The plan recommended a bedside commode and super absorbent diapers for nighttime toileting needs. His adult son lives with him. The 11 hours per day 7 days per week is sufficient to provide him the assistance he needs to function in his home and to help him with his activities of daily living. The decision to deny 24 hours per day 7 days per week live-in care is upheld. 

Based on the above, the insurer's denial must be upheld. 

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

The medical necessity for Personal Care Aide (PCA) services, Live-In, 24 hours per day, 7 days per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic breast cancer to liver
Treatment: Outpatient procedure (37243 x 1, 37242 x 1), radioactive treatment of liver cancer
The insurer denied coverage for outpatient procedure (37243 x 1, 37242 x 1), radioactive treatment of liver cancer.
The denial is overturned.

This is the case of an adult patient who presented with metastatic breast cancer to liver. Patient was treated on clinical trial. Patient has progression of liver disease. Patient was treated with second line therapy. The disease in liver progressed and was evaluated for liver directed treatment.

This is a young patient with liver metastasis which has progressed. Patient was evaluated for Stereotactic body radiation therapy (SBRT) but was not recommended. The disease is near portal vein and probably not a candidate for radio frequency ablation. Selective internal radiation therapy (SIRT) has been used for primary and metastatic liver cancers with good success rate. There are several published data to support SIRT for metastatic breast cancer to liver.

On the basis of the available published evidence, SIRT is feasible and effective in treating patients with breast cancer with liver metastasis. Patients with lower hepatic tumor burden and without extrahepatic metastasis demonstrated more survival benefit.

One of the newest methods of inoperable lesion treatment is radioembolization (SIRT). Intravascular administration of microspheres containing radioisotope 90Y allows delivery of a higher dose of radiation directly to the tumor than traditional radiation with an external beam, while maintaining a small dose to healthy liver. Conducted clinical studies confirm the efficacy and safety of SIRT. It is an interesting alternative to other ways of treatment.

Outpatient procedure (37243 x 1, 37242 x 1), radioactive treatment of liver cancer is considered medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for outpatient procedure (37243 x 1, 37242 x 1), radioactive treatment of liver cancer is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a woman who presented following a bicycle accident in which she collided with another bicycle rider and fell off her bike. There was reported loss of consciousness at the scene of the accident. She was not wearing a helmet. Past medical history is notable for asthma and Sjogren's. Vitals signs at the time of presentation were normal. Glasgow Coma Score was 15/15. At the time of presentation, the patient complained of lip, posterior scalp, and right wrist pain. Evaluation revealed no focal neurological deficit. There was a laceration of the posterior scalp. Imaging with computed tomography (CT) scan identified a 3- millimeter (mm) right subdural hematoma. She was admitted to the hospital and provided pain management, frequent neurological checks, pulse oximetry, and repeat CT imaging. 

The inpatient admission was not medically necessary for this patient. This patient presented to the hospital following a bicycle collision. While there was a reported transient loss of consciousness at the scene of the accident, she was awake and alert at the time of hospital ED presentation with a Glasgow coma score of 15/15. A lower level of care would have satisfied the clinical needs of this patient. This patient had a small subdural hematoma based on CT imaging. She was determined by the neurosurgery service to be neurologically and hemodynamically stable and nonoperative. There was no infection, no vertebral fracture, no compartment syndrome, no anticipated surgical intervention, no evidence for limb threatening injury, no suspicion of abuse or neglect and no ongoing severe pain that required inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a man who presented to the hospital emergency department (ED) with symptoms of abdominal pain and nausea of one-day duration. He reported 10 episodes of diarrhea prior to ED presentation. Comorbid health conditions included hyperlipidemia, hypertension, gastroesophageal reflux disease (GERD), and diabetes. His ED evaluation included labs and computed tomography (CT) scan that showed dilated small bowel without high grade obstruction. This was thought to be consistent with small bowel obstruction or ileus. At the time of presentation, the patient was without fever and vital signs were normal. 

The inpatient hospital stay was not medically necessary. There is no compelling reason why this patient could not have safely and appropriately been treated with a lower level of care.
This patient presented to the hospital just after midnight with symptoms of abdominal pain, nausea and diarrhea. Imaging suggested the possible diagnosis of small bowel obstruction or ileus. In the course of evaluation, within one day of presentation, the patient had improvement/resolution of the abdominal complaints. There were no complications or other clinical issues that mandated inpatient care. The patient remained stable. Diet was advanced and he was discharged from the hospital in the afternoon.
Inpatient level of care was not medically necessary. A lower level of care would have permitted for the surgical assessment, IV fluid, IV antiemetics, and imaging. The patient was clinically stable throughout the period of monitoring as supported by the corresponding medical records.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary.
Inpatient hospital.

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

The patient is a female with a history of an appendectomy who presented with sudden onset of sharp right flank pain associated with nausea, hesitancy urinating, subjective fevers, and chills for one day. She denied chest pain, shortness of breath, cough, abdominal pain, vomiting, or diarrhea. 

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with subjective fevers, flank pain, and dysuria for one day. She was febrile on presentation but otherwise hemodynamically stable. She was diagnosed with acute pyelonephritis. She did not have respiratory distress, acute kidney injury, elevated lactate, or other signs of acute organ dysfunction. She did not have severe pain, nausea, or vomiting. She did not have severe or persistent changes in mental status. She did not have an immunocompromised state or other co-morbid conditions that put her at higher risk of complications. She did not have emphysematous pyelonephritis, a renal abscess, urinary tract obstruction, or foreign bodies identified on imaging. She improved expectantly and did not have a clinical worsening of her condition that required a higher level of care. She could have been safely managed at a lower level of care with subsequent transition to outpatient follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Gastrointestinal Bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has metastatic colon cancer and was on chemotherapy and immunotherapy.  The patient had a recent admission for rectal bleeding and an ulcerated area was found on colonoscopy in the descending colon. The patient now returned with some rectal bleeding. The patient was hemodynamically stable. There was no active bleeding noted while in the hospital. The hemoglobin was 9.0. A repeat colonoscopy showed no active bleeding. The ulcerated area was noted to be smaller in size as compared to the previous colonoscopy.  PuraStat was applied. The hemoglobin remained stable.
Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-182 for Lower Gastrointestinal Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy, severe anemia, peritoneal signs, and an inability to maintain oral hydration after observation care.
This patient had a known ulcerated lesion in the patient's colon. The patient presented with a small amount of bleeding. However, the patient was not bleeding in the hospital and the colonoscopy was negative for bleeding. The patient was stable to have had the repeat colonoscopy performed with observation care. The PuraStat could have been applied with an outpatient colonoscopy. The patient did not meet MCG criteria for admission for Lower Gastrointestinal (GI) Bleeding. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with medical history of hypertension, hyperlipidemia, traumatic brain injury, benign prostatic hyperplasia, hepatic steatosis, peptic ulcer disease, and daily alcohol use. He presented to the emergency department with epigastric pain, vomiting with blood, and blood in bowel movements. He had used 3 g (grams) of Tylenol that day and reported consumption of four glasses of wine daily. He reported unintentional weight loss of 60 pounds over 18 months. Vital signs were notable for elevated blood pressure of 156/103 and rapid pulse of 105/minute. Physical examination was notable for mild distress and diffuse abdominal tenderness to palpation. 

The inpatient hospital admission was not medically necessary. Although the patient presented with markedly elevated liver enzymes and bilirubin, and the etiology was suspected to be alcohol and Tylenol use with concurrent shock liver, there was no evidence of ascending cholangitis, decompensated cirrhosis, or acute liver failure in this case. No other causes for hepatitis were found, or other complications such as choledocholithiasis, hepatic abscess, or sepsis. He appropriately started on supportive therapy with N-acetylcysteine, and his liver enzymes and bilirubin improved steadily. The interventions performed during the stay, including monitoring, labs, imaging, specialist consultations, and monitoring for alcohol withdrawal, could have been performed in sequence at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath, Heart failure.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This female patient initially presented to the emergency department with concerns about shortness of breath. The pertinent history included hypertension and diabetes mellitus.  The initial examination documented the patient as alert and oriented with a well-healing left toe amputation site. An electrocardiogram (EKG) revealed sinus tachycardia without acute ischemic changes. A chest radiograph revealed vascular congestion and bilateral infiltrates. An x-ray (XR) of the foot did not reveal osteomyelitis. Lasix 40 milligrams (mg) intravenous (IV) was administered with clinical improvement. The patient was admitted to the hospital with concerns about new onset congestive heart failure and to rule out acute coronary syndrome. The treatment plan included serial cardiac enzymes, telemetry, echocardiogram, and therapeutic anticoagulation. The patient had persistent tachycardia and SpO2 of 98 percent (%). An echocardiogram revealed regional wall motion abnormalities and a newly decreased left ventricular ejection fraction (LVEF) of 20%. The impression was acute systolic congestive heart failure due to ischemic cardiomyopathy and type II non-ST elevation myocardial infarction (NSTEMI). At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence-based literature, and standards of care, acute inpatient level of care was medically necessary for the entire admission.
The patient did not have a history of congestive heart failure and presented with progressive shortness of breath. Initial evaluation documented tachycardia, hypoxia (88% on room air), elevated troponin, elevated BNP, and pulmonary congestion on chest radiography. Serial troponins were obtained and continued to increase. An echocardiogram revealed a new severely reduced LVEF of 20% with diffuse regional wall motion abnormalities suggestive of ischemic cardiomyopathy. Therapeutic anticoagulation, anti-platelets, and loop diuretics were provided to address acute systolic congestive heart failure with concerns for acute coronary syndrome. A cardiac catheterization was performed which revealed 3-vessel coronary artery disease including a 90% LAD occlusion. The clinical indications for admission to the inpatient level of care were met. The patient had acute myocardial ischemia causing or associated with acute heart failure. [3] Therefore, according to the aforementioned literature, an acute inpatient level of care was medically necessary for the entire admission.