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

Diagnosis: Vomiting. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient had a history of immunosuppressive disease and a ventral hernia repair and presented with abdominal pain and vomiting for a month. She had multiple previous emergency room (ER) visits and no evidence of intestinal obstruction was found. She initially had a tachycardia but it resolved. There was no abdominal rebound or guarding. An endoscopy showed a small hiatus hernia and Grade B esophagitis. She was treated with famotidine and Zofran and was then able to tolerate a diet. The initial potassium was 2.5 and then went up to 2.8 on the same day. 

Clinical indications for admission for Vomiting (Milliman Care Guidelines (MCG) M-370) include vomiting due to a severe metabolic derangement, hemodynamic instability, severe vomiting that is not responsive to treatment with observation care, severe electrolyte abnormalities, acute renal failure, or an inability to maintain oral hydration after observation care. Severe electrolyte abnormalities are defined as a potassium less than 2.5 that is not corrected to near normal after observation care treatment. The patient did not have these conditions. 

This patient had vomiting that may have been related to marijuana use. Intravenous (IV) hydration with potassium replacement, Famotidine, and antiemetics could have been given in the ER with observation status. Her tachycardia resolved rapidly. She did not meet MCG criteria for admission for Vomiting. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was 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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 
The denial is upheld. 

The patient is a pregnant female at 16 weeks and 4 days of gestation with a history of asthma, eczema, and hidradenitis suppurativa. She presented to the emergency room (ER) with complaints of shortness of breath (SOB). She tried using an inhaler and nebulizer at home, but it did not work. There was wheezing in all lung fields. Respiratory syncytial virus (RSV) testing was positive. The patient was admitted with an asthma exacerbation. The care plan consisted of administering nebulizers every 4 hours (Q4H) and then Q6H, administering intravenous (IV) steroids, administering supplemental oxygen as needed (PRN), administering cough medicine PRN (as needed), and maintaining oxygen saturation levels within normal limits (WNL). The patient left against medical advice (AMA). 

Acute asthma exacerbations are common during pregnancy and increase the risk of preeclampsia, gestational diabetes, placental abruption and placenta previa. Intensive monitoring of both mother and fetus is essential. 

Fetal heart rate monitoring is the best available method for determining whether the fetus is adequately oxygenated. After 23 to 24 weeks of gestation, noninvasive fetal heart rate monitoring is appropriate during asthma exacerbations requiring emergency department treatment or hospitalization. This patient was less than 15 weeks, fetal heart monitoring was not medically necessary as the fetus was too premature for any intervention. 

Asthma exacerbation is usually treated in the emergency department (ED). Patients should be reassessed frequently. After the first hour of therapy, some patients may be ready for discharge while others need hospitalization or further emergency department management. 

Patients are admitted to the hospital in a setting with a high level of patient monitoring and care if they do not respond well after an additional few hours of emergency department therapy; if they have symptoms of coughing, wheezing, and shortness of breath that preclude self-care; and/or have a peak expiratory flow (PEF) less than or equal to 60 percent of predicted or their personal best value. 

This patient does not fulfill the above criteria, so admission was not medically necessary.
Note that from an obstetrical management point of view, admission was not medically necessary as this was a very early pregnancy with no plan for any obstetrical intervention. 

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

The inpatient hospital admission is not considered medically necessary for this patient. 

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

Diagnosis: Interstitial lung disease.
Treatment: Genetic Testing (comprehensive mitochondrial nuclear gene panel).
The insurer denied the Genetic Testing (comprehensive mitochondrial nuclear gene panel).
The denial is upheld.

The patient is a male. The service under review is Genetic Testing (interstitial lung disease gene panel). This service was denied as not medically necessary and this decision is being appealed.

The patient's medical history includes premature birth, bronchopulmonary dysplasia, pulmonary hypertension, chronic respiratory failure, oxygen dependence with inability to wean to room air), dysphagia, lungs continue to have crackles on exam. Thus, he is suspected of having an interstitial lung disease, and the genetic testing was ordered to air with management and prognosis. The requested test is for ABCA3 (ATP binding cassette subfamily A member 3), SFTPB (surfactant protein B), SFTPC (surfactant protein C), NKX2-1 (NK2 homeobox 1)/TTF1 (thyroid transcription factor 1), CSF2RA (colony stimulating factor 2 receptor subunit alpha), CSF2RB (colony stimulating factor 2 receptor subunit beta), SCL7A7 (solute carrier family 7 member 7), GATA2 (GATA binding protein 2), MARS (Methionyl-TRNA Synthetase 1), FOXF1 (forkhead box F1). During a previous review, only 4 of these 10 were approved.

No, the requested health service is not medically necessary.
There is no published literature to support the requested genetic testing. A search of the National Library of Medicine was made using the Pubmed search engine using the terms "interstitial lung disease genetic," with limits of publication date of 5 years and pediatrics (age 0-18). This did not yield a single published practice guideline. Given the lack of support for the requested testing, it is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient
There are no published practice guidelines that contradict the plan's determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subacute hemorrhage (SAH). 
Treatment: Sub-Acute Rehabilitation. 

The insurer denied Sub-Acute Rehabilitation. 
The denial was upheld.

The patient is a female who has a diagnosis of complications from a brain bleed. The rehabilitation stay was primarily for the complications of a brain bleed, specifically a subacute hemorrhage (SAH). The patient's other diagnoses at time of admission include, essential hypertension, alcohol abuse, cerebellar stroke syndrome, reduced mobility, fatigue, weakness, abnormalities of gait and mobility, unsteadiness on feet, radiculopathy of both cervical and lumbar region, cerebrovascular disease, reduced mobility, limitations of activities due to disability, nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis affecting left side, gastro-esophageal reflux disease, major depressive disorder, lipoprotein deficiency, chronic embolism and thrombosis of vein, and degenerative disease of nervous system. Physician documentation documents left arm weakness and minimal left leg weakness which is rated by physician on manual muscle testing as 4/5 strength of left upper extremity and 4 plus (+)/5 strength of left lower extremity.
At issue is the medical necessity of Sub-Acute Rehabilitation. 

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Sub-Acute Rehabilitation is not medically necessary for this patient.
Based on available documentation and the diagnosis being treated, continued Sub-Acute Rehabilitation is not medically necessary to achieve health and functional goals. The patient achieved level of function appropriate for discharge according to the documentation. This included minimal assistance for dressing and bed mobility. The patient was walking 300 feet with a cane and up 12 stairs. The patient was not on intravenous fluids, antibiotics, or enteral feeds. The patient did not have complex wound care. She was tolerating wound care and had well-controlled pain.
Therefore, the requested health service/treatment of Sub-Acute Rehabilitation is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral hematomas. 
Treatment: Inpatient admission. 

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

The patient is a transgender male who was admitted following discovery of bilateral hematomas following bilateral mastectomies. The patient was transferred from the post-anesthesia care unit (PACU) at the ambulatory surgical center following hematoma evacuation for blood pressure support and further monitoring. Overnight on post-operative day zero (PODO) the patient required two units of packed red cells and was able to be weaned off pressor support. The patient was deemed stable for discharge from the post-anesthesia care unit (PACU) and was transferred to the surgical floor for further recovery. Hematology was consulted given no prior history of bleeding abnormalities. The patient was monitored throughout the day and deemed to be stable. Cardiology was consulted for sinus tachycardia and recommended outpatient follow up for echocardiogram if the tachycardia does not resolve with pain control. At time of discharge, the patient was tolerating a regular diet, voiding/stooling spontaneously, ambulating, and pain was well-controlled. The patient and family felt ready for discharge.

No, the proposed inpatient admission was not medically necessary. 

The records document that the patient was admitted for acute blood loss anemia following evacuation of breast hematomas.  He required pressor support and two units of blood transfusion following the procedure. He was discharged on post-operative day one (POD #1). The patient required acute care nursing for pressor support and blood transfusions. He could have been cared for at an observation level of care.  According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48-hours or less, but can be up to 72-hours in certain situations." This patient required close observation for 24-36 hours but was medically stable and ready for discharge home after receiving blood transfusions, pressor support and hematology evaluation.  The patient received the same active diagnostic and therapeutic services used during an inpatient hospitalization but for a short period of time (less than 48 hours) and therefore could have been managed at an observation level of care. 

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

The health plan acted reasonably. The patient could have been managed at an observation level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Irritable bowel syndrome. 
Treatment: Motegrity. 

The insurer denied coverage for Motegrity. 

The denial is overturned. 
 
The patient has a history of chronic constipation and irritable bowel syndrome (IBS). A previous computed tomography (CT) scan showed a high fecal burden with a distended colon. She has been on Miralax and Linzess but had a poor response. She was then started on Motegrity and has had some improvement but continues to have constipation. 

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacological therapy. It states that prucalopride is a 5HT4 (5-Hydroxytryptamine receptor 4) prokinetic agent that has been shown to be superior to the placebo and was well tolerated for the treatment of constipation. The improvement in quality-of-life scores was maintained up to 18 months. It has Food and Drug Administration (FDA) approval for the treatment of chronic idiopathic constipation in adults. 

There are several approved drugs for the management of chronic idiopathic constipation. These include linaclotide, plecanatide, lubiprostone, and prucalopride. However, the physician's letter states that the patient has already failed Linzess and Miralax. Since the patient has already failed the formulary alternative of Linzess, giving Motegrity is an appropriate treatment. The formulary drug Linzess caused abdominal distention and was not effective. Her physician writes in the most recent progress note submitted that since her last visit her symptoms have been mostly under control and that she was having 1-2 soft bowel movements a day although she still feels a sense of incomplete evacuation. The requested drug Motegrity does appear to be more effective than the formulary drug Linzess. Since the patient has tried and failed Linzess, the denial of Motegrity is overturned. 

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. 

The formulary drug is expected to be ineffective. 

The not formulary drug is expected to be more effective that the formulary alternatives. 

The carrier's denial of Request for Formulary Exception for Motegrity (prucalopride) to treat constipation is overturned. The medical necessity of Motegrity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee pain.
Treatment: Inpatient Hospital Admission.
The insurer denied inpatient hospital admission.
The denial is overturned.

The patient is an adolescent male, who presented with right knee pain. He was diagnosed with a displaced osteochondral fragment. He was also diagnosed with genu valgum and leg length discrepancy. The patient underwent several procedures, including arthrotomy, MACI (matrix autologous chondrocyte implant) biopsy and distal femoral osteotomy. He had OCD (osteochondritis dissecans) fixation with bone graft. His post-surgical course was complicated by nausea and pain. He had difficulty being mobilized. He was then discharged on postoperative day #2.

The Inpatient Hospital Admission was medically necessary.

The medical records show a complex and unique surgical procedure was performed. There were many steps including arthroscopy, biopsy, fixation of fragment and osteotomy. The surgery began at 1628 and was completed 0028, meaning that the operation and anesthesia were five and a half hours. 

This type of surgery is quite painful. A femoral osteotomy was performed where the distal femur is cut. There is alignment provided with placement of screws and plate. There is risk of compartment syndrome and stretch to neuromuscular structures. Practitioners who perform this type of osteotomy will admit the patient for neuromuscular checks. The patient in this case had a Foley and required PCA (patient-controlled analgesia). His PT (physical therapy) was slow, with limits reported. Based upon the complexity, duration and type of surgery, the admission and length of stay were appropriate and consistent with standard of care. No other level of care would be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis. 
Treatment: Full Hospital Admission. 
The insurer denied: Full Hospital Admission. 
The denial is upheld. 

The patient is an adult female, without any significant past medical or surgical history who presented to the emergency department (ED) with complaints of itching, burning and progressively worsening erythema and warmth of the left upper arm for three days. The patient stated that she woke up and noted itching, burning, and redness to the left upper arm. She reported that the swelling and redness was getting worse with pain and tightness. On examination, the patient's left upper arm was noted to have warmth and erythema involving an area about 20 centimeters (cm) by 15 centimeters (cm). Lab studies showed a white blood cell (WBC) count of 12.6, hematocrit of 44.5, and lactate 1.1. The patient was started on intravenous fluids of normal saline and given a dose of intravenous antibiotics in the emergency room. The Plan was made to obtain Doppler evaluation of the upper extremity to rule out deep vein thrombosis (DVT). On day #2, the patient continued to show improvement, continued to be afebrile, and have stable vitals. The patient was able to tolerate oral intake. The involved area of cellulitis was improving. The patient continued to show improvement. The involved area of cellulitis was improving, and a Plan was made to transition to oral antibiotics on discharge. 

The inpatient admission was not medically necessary. 

The patient had not tried and failed outpatient oral antibiotics before presentation. For the duration of her stay, the patient was afebrile and had stable vital signs. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. The patient's diagnosis had been established clinically and based on the results of the investigations. Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as high fever, shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress and in view of these facts of the patient's clinical status, ongoing risk of deterioration was low since diagnosis had been established and patient was responding appropriately to the treatment. The patient did not have any acute complications during this time. No high frequency, high complexity, or high-risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pilonidal cyst.
Treatment: Pilonidal Cyst Excision at a Hospital.
The insurer denied: Pilonidal Cyst Excision at a Hospital.
The denial is upheld.

The patient is an adult female with recurrent infection from pilonidal cysts. She underwent excision and closure of the cysts. Services were denied due to the procedure being performed in a hospital outpatient setting. The service did not meet hospital outpatient criteria.

The proposed pilonidal cyst excision at a hospital was not medically necessary.

Per the documentation, this procedure was performed in a low-risk individual who underwent a low-risk procedure. This procedure can be done in an ambulatory center and does not need to be in a hospital outpatient setting. Therefore, the proposed pilonidal cyst excision at a hospital was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right knee replacement, coronary artery disease, cancer, depression, anxiety, and diabetes. 
Treatment: Increase Personal Care Assistance (PCA) Services to 42 Hours per Week. 
The insurer denied: Increase Personal Care Assistance (PCA) Services to 42 Hours per Week. 

The denial is overturned. 

This patient is an elderly female who has conditions including right knee replacement, coronary artery disease, cancer, depression, anxiety, and diabetes. She is appealing denial of an increase personal care assistance (PCA) services from 36 to 42 hours per week. 

Uniform Assessment System (UAS) evaluation completed recently shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, shopping, bathing, and dressing; limited assistance with personal hygiene, walking, locomotion, and toileting; and independent with bed mobility and eating. She does not have incontinence. 

Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with shopping and toilet use. 

The proposed treatment is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient is appealing the denial of an increase in personal care assistance (PCA) services from 36 to 42 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient is independent with bed mobility and eating. Otherwise, she requires assistance with activities of daily living (ADLs). Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with shopping and toilet use. This patient requires assistance with meal preparation, housework, shopping, managing finances and medications, shopping, bathing, dressing personal hygiene, walking, locomotion, and toileting. The required assistance with activities of daily living (ADLs) and decline in the patient's level of functioning between Uniform Assessment System (UAS) evaluations, supports the proposed increase in personal care assistance (PCA) services. The approved personal care assistance (PCA) 36 hours per week is inadequate to meet this patient's needs for assistance with activities of daily living (ADLs). The proposed increase in personal care assistance (PCA) services to 42 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal malocclusion, crowding.
Treatment: D8020 Braces.
The insurer denied: D8020 Braces.
The denial is overturned.

The patient is a school-aged female. The request is for orthodontic benefits. The patient has a Class I skeletal malocclusion with severe upper and lower arch crowding. She has a posterior right crossbite and an anterior crossbite with gingival attachment loss. Also, the patient has impacted maxillary lateral incisors. The prior health plan denial was due to "not having a poor bite position".

The proposed treatment is medically necessary.

The patient has impacted maxillary right and left permanent lateral incisors. She also has an anterior crossbite (between teeth #'s 9 and 24) with gingival attachment loss. Both of these 
conditions are "automatic qualifiers" according to the handicapping index scale. The case has medical necessity and orthodontic treatment is needed to correct these problems.