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


Diagnosis: Digestive System/ Gastrointestinal - Abdominal/Stomach Pain 
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

This female patient presented to the emergency department (ED) complaining of abdominal pain and headache. Her medical history was remarkable for gastroesophageal reflux disease, gastritis, and morbid obesity. Her blood pressure was 172/91 millimeters of mercury (mmHg) with a heart rate of 90 beats per minute. Her room air oxygen saturation was 100%. Her abdominal exam was benign, as was her neurologic exam. Her electrocardiogram (EKG) showed sinus rhythm without acute changes. Her serum troponin I level was 0.28 and was .25 when remeasured. A chest x-ray showed no acute pathology. A computed tomography (CT) scan of the abdomen and pelvis showed no acute abdominal or pelvic pathology. There was stable cardiomegaly compared to prior studies and a small pericardial effusion. The patient was treated with famotidine and antacids, and her symptoms resolved. She was admitted to the hospital due to concerns regarding her elevated troponin level. Her next troponin I level was .07. An echocardiogram was performed and showed normal left ventricular systolic function. Myocardial perfusion imaging with dipyridamole stress was planned; however, the test was canceled because the patient had ingested caffeine. She was discharged with plans for an outpatient stress test.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
This patient presented with abdominal pain. Due to elevation of her serum troponin level in the indeterminate range, there was concern regarding the possibility of acute coronary syndrome, and she was admitted to the hospital for further testing. However, she was hemodynamically stable, with no ischemic electrocardiographic changes. She did not require intensive monitoring or continuous infusion and titration of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under an alternate level of care. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral flat foot deformity

Treatment: custom shoe inserts (L3020 x 2)

The insurer denied coverage for custom shoe inserts (L3020 x 2)

The denial is overturned

The patient is a teen female with long history of painful bilateral flat foot deformity treated with custom orthotics for over 5 years. The patient returned to the podiatrists' office with complaints of severe cramping, not responsive to stretching and her latest pair of orthotics from over 1 year ago. The notes clearly indicate that the patient has tried and failed over the counter options and would benefit from continued use of custom orthotics. The patient also had extended physical therapy with no relief. X-rays taken of the patient, along with magnetic resonance imaging (MRI) of the bilateral lower extremities confirm calcaneonavicular coalition.  

The patient was clearly benefiting from the use of orthotics and had been able to deal with the day-to-day pain with the use of custom orthotics for over 5 years. As such, it would have been beneficial to continue with the custom orthotics to avoid need for surgical intervention. 

The use of orthotics in this type of coalition will allow for limitation of motion and thus decreased pain. (1) Studies have shown that if conservative therapy works surgery can be avoided (2) and, in this case, orthotics had been helping the patient but had just given out and a new pair was needed. Most orthotics if worn on a daily basis do give out after one year of use and this case was not different.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for custom shoe inserts (L3020 x 2) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a male without a past medical history who presented to the emergency room (ER) with abdominal pain of two days duration that was associated with nausea and vomiting as well as fevers at home. He was febrile but was otherwise hemodynamically stable. He had abdominal tenderness in the right lower quadrant with a positive McBurney's point and positive obturator sign. He had a leukocytosis of 21.62 and the computed tomography (CT) scan showed acute appendicitis with a possible perforation.

General surgery was consulted and the patient was admitted and started on intravenous (IV) antibiotics, analgesics, antiemetics and the patient was kept nothing by mouth (NPO). He responded well to conservative management and his leukocytosis resolved. The repeat CT scan showed no evidence of an abscess. He was started on clear liquids and his diet was advanced. He was discharged home on oral antibiotics and an outpatient follow up.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The requested health service/treatment of a full hospital admission was medically necessary for the patient. The patient had acute appendicitis with a complication (perforation). He had evidence of systemic inflammatory response syndrome (SIRS) and required a possible surgical intervention. 

Appendicitis is one of the most common causes of acute abdominal pain in adults and children, with a lifetime risk of 8.6 percent (%) in males and 6.7% in females. Findings from the history, physical examination, and laboratory studies aid in the diagnosis of acute appendicitis. Right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant are the best signs for ruling in acute appendicitis in adults.

The recommended first-line imaging consists of point-of-care or formal ultrasonography. An appendectomy via an open laparotomy or laparoscopy is the standard treatment for acute appendicitis. However, IV antibiotics may be considered first-line therapy in selected patients. Pain control with opioids, nonsteroidal anti-inflammatory drugs, and Acetaminophen should be a priority and does not result in delayed or unnecessary intervention. A perforation can lead to sepsis and this occurs in 17% to 32% of patients with acute appendicitis. A prolonged duration of symptoms before surgical intervention raises the risk. In moderate to high-risk patients, surgical consultation should be accomplished quickly to reduce morbidity and mortality resulting from perforation.

The patient had acute complicated appendicitis with SIRS and was at risk for sepsis given his perforation and hence an inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Enteritis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This case involves an adult patient who presented to the Emergency department with a 1-week history of epigastric and chest pain. The patient also had complaints of nausea and vomiting. The patient had a dialysis port on the right chest and an insulin pump. Past history was significant for end-stage renal disease as well as hypertension, asthma, and diabetes. Physical exam noted epigastric tenderness. The nephrology consultation reported the patient was noted to have mild pulmonary edema on an x-ray. The glucose was noted at 529. It was noted the patient currently had volume overload and was recommended for dialysis. A Computed Tomography (CT) scan of the abdomen and pelvis completed revealed thickened, edematous small bowel ileus with surrounding fat stranding suggestive of severe enteritis. It was noted the hospital course included treatment with intravenous (IV) antibiotics and medication management. The patient was discharged to follow-up with outpatient care. The determination letter reported the inpatient admission was not medically necessary as the patient was not unstable. The patient stay was approved at the observation level of care. The appeal letter reported the patient had severe enteritis and uncontrolled diabetes with need for immediate hemodialysis. The patient was admitted for further management. Treatment included IV fluids, IV medication, consultation, medication management, and lab testing.

This patient presented with severe enteritis, fluid overload with evidence of congestion on x-ray along with hyperglycemia. The patient was noted to have mild pulmonary edema on x-ray. The glucose was noted at 529. Treatment included IV fluids, IV medication, consultation, medication management, and diagnostic workup. The combination of these issues is not appropriately managed during a period of observation. The inpatient admission was medically necessary for this patient.

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

The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld

This is a pediatric patient referred to the emergency room (ER) by the pediatrician. There was a one-day history of fever and coughing. When the child developed shortness of breath the child was taken to the pediatrician for treatment. The pediatrician administered albuterol in the office and when there was no improvement in respiratory distress the pediatrician referred the child to the ER for additional treatment.

In the ER, the child was noted to have a pulse oximeter reading of 93-94%. The mother complained of a decrease in oral intake and urine output. The mother indicated that there had been only one wet diaper on that day. The mother also indicated that the child was having abdominal and flank pain. The child's temperature was 100.9 degrees Fahrenheit in the ER and on physical examination the child was not noted to be in acute respiratory distress and there was mild wheezing audible bilaterally. The child was treated with DuoNeb nebulizer treatments and prednisone for the wheezing. A chest x-ray showed prominent perihilar markings and a possible right upper lobe infiltrate. The urine specific gravity was elevated at 1.034 and the serum C-reactive protein (CRP) was elevated at 21.65. The child was noted to have a productive cough with yellow sputum. The child was started on intravenous (IV) fluids for dehydration and ceftriaxone for the pneumonia. Following treatment in the ER the child was still noted to have mild wheezing and the decision was made to admit with a diagnosis of dehydration and possible pneumonia for ongoing treatment with IV fluids, albuterol every 4 hours, IV ceftriaxone and steroids. The child did not require oxygen supplementation in the ER. 

The patient was treated appropriately in the ER for a cough, wheezing and mild dehydration. The patient was not noted to be in acute respiratory distress on arrival to the ER and did not require oxygen supplementation. There is no note in the medical record to indicate that the patient required an IV bolus of normal saline for dehydration and there is no documentation of physical findings to support the diagnosis of dehydration. The patient could have been treated with IV normal saline fluid boluses to treat the risk of dehydration. Since the patient did not require oxygen supplementation and since the patient was stable enough to require albuterol only every 4 hours, the patient could have been discharged safely to home with prednisone, albuterol, and an antibiotic with a follow up appointment with the pediatrician in 24-48 hours. 

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: Left knee pain
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld 

This is a patient with a history of asthma, diabetes mellitus and hypertension. The patient presented to the hospital for a left total knee arthroplasty (TKA). The physician identified that the patient's American Society of Anesthesiologists (ASA) score was 3, therefore the patient was admitted. Post left TKA antibiotics and deep vein thrombosis (DVT) prophylaxis were given. The patient's pain was controlled, and the patient worked with physical therapy (PT) and occupational therapy (OT). Once the patient was stable, the patient was discharged to follow-up with Orthopedics.

The medical records showed a non-complicated post-surgical course. The operation itself was approximately 3 hours. There were no problems with performing the procedure. The physician utilized robotic assistance. Blood loss was limited to 150 cubic centimeters (cc). No drain was placed. The vital signs were stable. There was no bleeding. Pain levels were tolerated. The record noted disposition to home pending PT and OT. The PT record documented the ability to walk 200 feet with a walker. The subsequent clinical record on that date noted disposition for home. These findings do not substantiate necessity for an inpatient admission. There was no need for subspecialty consultation, additional imaging nor other service.

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld

Based on clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department with a chief complaint of right lower quadrant abdominal pain. The patient underwent an uneventful laparoscopic appendectomy and was discharged the same day. There were no reported complications related to the procedure. An outpatient appendectomy is safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation.

The inpatient hospital stay was not medically necessary. The patient presented to the emergency department with a one-day history of right lower quadrant abdominal pain. There was nausea but no vomiting. The patient had a Computed Tomography scan that demonstrated nonperforated acute appendicitis. The white blood cell count was 11.98. The patient underwent an uneventful laparoscopic appendectomy. There were no reported complications. Admission may be necessary for patients with severe systemic illness (such as sepsis), poorly controlled comorbidities (such as chronic obstructive pulmonary disease, chronic heart failure), or complications from the procedure (such as infection, bleeding) that require more than 24 hours of postoperative care. Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis. Therefore, the requested hospital stay should be observation status. 

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: Trouble Breathing
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female. She presented to the emergency room with worsening shortness of breath. The patient has history of COPD (chronic obstructive pulmonary disease) and was noticed to have low oxygen levels at home.

In the ER (emergency room), the patient was hypoxic and was placed on supplemental oxygen, IV (intravenous) steroids, nebulization and antibiotics. The patient was admitted to acute inpatient level of care for the management of COPD (chronic obstructive pulmonary disease) exacerbation.
The acute inpatient hospitalization was denied coverage by the 
health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The patient was admitted to acute inpatient level of care for 3 days for COPD (chronic obstructive pulmonary disease) exacerbation. At the time of admission, the patient was 
hemodynamically stable. The patient was not in severe respiratory distress. The patient's respiratory status had improved with ER (emergency room) care. The patient was able to ambulate and tolerate oral diet. The acute inpatient admission was not medically necessary. Given that the patient's signs and symptoms due to COPD (chronic obstructive pulmonary disease) exacerbation improved significantly with ER (emergency room) care, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment provided in this patient was reasonably expected to be provided but does not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent hypotension.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female. Her past medical history includes lupus, DVT (deep venous thrombosis) and POTS (postural orthostatic tachycardia syndrome). She presented in transfer from another hospital with persistent hypotension. She had presented to the other hospital with failure to thrive.
The patient's vital signs were stable. Her blood pressure was 143/73. Her exam was unremarkable. She was admitted with plan for Cardiology evaluation. Midodrine was continued. 
She was noted to have POTS (postural orthostatic tachycardia syndrome) on the day after admission with supine systolic 115 and standing systolic 86. The plan was to continue midodrine and fludrocrotisone. Three days later, the patient's blood pressure was 87/55. She was tolerating medications. The plan was for discharge to rehab. The day after, the patient was feeling well. Her blood pressure was 90/62. The plan was to 
continue current management. Staff were looking for placement for the patient. On the following day, the patient was awaiting rehab placement.

The requested Inpatient Hospital Admission was not medically necessary.

This patient with history of POTS (postural orthostatic tachycardia syndrome) was admitted for Cardiology evaluation due to persistent hypotension. Evaluation showed blood pressure consistent with POTS (postural orthostatic tachycardia syndrome). There was no significant change from baseline. Oral medication regimen had already been established with no significant change. During hospital stay, she was monitored for oral intake. Discharge was delayed pending placement. During this hospital stay, the patient was clinically stable. She was not receiving intervention that required an inpatient level of care. Inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-polio syndrome, osteoarthritis, and depression

Treatment: consumer direct personal assistance services (CDPAS) 84 hours per week

The insurer denied coverage for CDPAS 84 hours per week

The denial is upheld

The patient is an adult female with chronic medical problems including post-polio syndrome, osteoarthritis, and depression. She lives alone in a private home. The patient is currently receiving 70 hours/week consumer direct personal assistance services (CDPAS) and requesting an increase to 84 hours/week. 

The Uniform Assessment System (UAS) report indicated that the patient's cognitive ability is documented as "Independent-Decisions consistent, reasonable and safe." She is also able to contact 911 in an emergency. The patient requires extensive assistance for bathing, lower body dressing, bed mobility and toilet transfer/use. She is continent of bowel and bladder. Activities such as personal hygiene and upper body dressing require only limited assistance and she is independent with eating. The patient has lower extremity plegia (secondary to polio) and is wheelchair dependent. However, she can self-propel her wheelchair in her home without assistance. She can also drive a motor vehicle with adaptive controls. The patient functional ability is much the same as documented in the prior UAS report. She remains cognitively intact. Her condition and functional needs are not at a level or unpredictable as to require the requested 84 hours/week. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved 70 CDPAS hours/week.  

The healthcare plan acted reasonably, with sound medical judgment and 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, as well as within a reasonable degree of medical certainty, the requested increase CDPAS 84 hours/week is not medically necessary.  

The insurer's denial of coverage for the consumer direct personal assistance services (CDPAS) 84 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Amaryl
The insurer denied Amaryl. 
The health plan's determination is overturned. 

This is a female diagnosed with Type II Diabetes Mellitus. This request is for Amaryl 4 milligrams (mg) Tab. As reported, due to adverse reactions and allergies to other medications, she was put on a cocktail of meds to lower her hemoglobin (HGB) A1C and control her BGs (blood glucose). 

Amaryl is medically necessary for this patient.
The denial reason is that the patient has not tried the formulary alternatives such as repaglinide or nateglinide. These medications are not of the same class as the requested medication. Furthermore, they are less effective than the requested medication with respect to A1c reduction. Given the fact that the patient has had an improvement in HGB A1c on the requested medication, Amaryl is consistent with generally accepted standards of medical practice and is therefore medically necessary.