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

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.  The denial is upheld.
The Inpatient Hospital Admission was not medically necessary.
The patient is a male with history of COPD (chronic obstructive pulmonary disease). He presented to the ER (emergency room) with shortness of breath and wheezing. The patient was found to be in COPD (chronic obstructive pulmonary disease) 
exacerbation. The patient was treated with oxygen, BiPAP (bi-level positive airway pressure), IV (intravenous) steroids in the emergency room. He was admitted to acute in hospital level of care.
The patient was admitted for the management of COPD (chronic
obstructive pulmonary disease) exacerbation. The patient was hemodynamically stable. The patient's symptoms improved with ER (emergency room) care. The patient's oxygen level was above 90%. The patient was able to tolerate oral diet and oral medications. Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care.
Therefore, given the above, the Inpatient Hospital Admission was not medically necessary.
The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Blood Pressure

Treatment inpatient emergency admission

The insurer denied coverage for inpatient emergency admission

The denial is upheld

The patient was admitted for elevated blood pressure and volume overload. She underwent routine hemodialysis for ultrafiltration and her condition responded appropriately and discharged in stable condition.  Her condition could have been treated safely under lower level of care per evidence-based literature.

An evidence-based specialty society guideline concludes that adult patients with severe hypertension (eg, SBP (systolic blood pressure) greater than 180 mm Hg or DBP (diastolic) greater than 120 mm Hg) without acute or worsening target organ damage (sometimes deemed a hypertensive urgency) can be treated with oral medication, and do not require inpatient car

Database analysis of a cohort of 552,569 patients (mean middle age years) discharged from an emergency department with a primary diagnosis of hypertension found that in the weeks after discharge the rate of intracerebral hemorrhage was exceedingly low (less than 0.02% [percent]), and not elevated to a statistically significant degree compared to the rate the same patients experienced over the same time period a year later [2]. In the same analysis, among the 10,288 patients discharged with a diagnosis of malignant hypertension, the rate was similarly low (0.03%), and also not different from the same time period a year later.

A multiyear database analysis of patients seen in a Canadian emergency department with a primary diagnosis of hypertension found in the last year of the study (25,950 patients, median age 64 years) that over 92% of patients were treated without admission to inpatient care [3].

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Altered mental status
Treatment: Inpatient hospital admission 
The insurer denied coverage for an inpatient hospital admission. 
The denial is overturned.

This patient reportedly was admitted to this inpatient hospital due to a change in mental status and physical complaints. He reportedly had confusion, bizarre affect, delusions, visual hallucinations, agitation, and erratic behavior. He reportedly had a positive toxicology for phenylcyclohexyl piperidine (PCP), cocaine, and Tetrahydrocannabinol (THC). He reported headache, chest pain, malaise, nausea, fatigue, and an elevated blood pressure of 154/102. There was suspicion of cerebral or cerebellar swelling on the brain computed tomography (CT). He reportedly was admitted to telemetry. He reportedly had neurology, neurosurgery, psychiatry, and urology consultations. He reportedly was cleared for discharge by them when he improved and was back to baseline mental status. 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Delirium reports that delirium frequently heralds a medical emergency and patients are usually managed in an acute-care hospital setting and patients with altered mental status are candidates for inpatient hospital treatment. Also, the MCG - Milliman Criteria Guidelines for Psychiatric Disorder: Common Complications and Conclusions reports that one meets criteria for hospitalization if one is a danger to self or others and not manageable at a lower level of care, if they have severe behavioral health issues such as hallucinations, or if a less restrictive level of care is not considered feasible until acute intervention is done. This patient had a change in mental status consistent with a delirium as the psychiatric consultant's impression was drug induced delirium and cannabis dependence and recommended substance rehabilitation when discharged. It was reported that he was not at baseline and had altered and changed mental status, confusion, bizarre affect, psychotic symptoms including delusions and visual hallucinations, agitation, and erratic behavior, and was actively using multiple serious substances as his toxicology was positive for PCP, cocaine, and THC, and had medical issues including headache, chest pain, malaise, nausea, fatigue, and elevated blood pressure of 154/102. 

As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment as he reportedly was discharged with referrals for outpatient treatment. It did not appear that the insurer acted reasonably, with good clinical judgment, or in the best interest of the patient then. 

The insurer's denial of coverage for inpatient hospitalization is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: knee injury.
Treatment: Outpatient Arthroscopic Knee Surgery (CPT 29881).
The insurer denied Outpatient Arthroscopic Knee Surgery (CPT 29881). 
The health plan's determination is overturned. 

This case describes a female patient with a complaint of left knee pain. The patient had undergone a prior left knee partial lateral meniscectomy for a known discoid lateral meniscus in the same knee. She, unfortunately, sustained a repeat injury to the left knee while playing sports and had recurrent pain. The patient failed conservative treatment for this repeat knee injury and a magnetic resonance imaging (MRI) scan confirmed a torn lateral meniscus with an associated paramedical cyst. The orthopedic provider recommended knee arthroscopy for either lateral meniscal repair versus partial lateral meniscectomy. 

The requested outpatient arthroscopic knee surgery for partial lateral meniscectomy (CPT 29881) was medically necessary for this patient. The provided medical records, in this case, a document that this patient had prior surgery on her left knee for a discoid lateral meniscus. The patient suffered a repeat left knee injury while playing sports which resulted in a recurrent lateral meniscal tear. This pathology was documented on an MRI scan of the left knee. The patient attempted conservative treatment for this injury but failed to improve. Due to the patient's young age, the orthopedic provider proposed arthroscopic knee surgery for either partial lateral meniscectomy or lateral meniscal repair depending on the intra-operative findings concerning the lateral meniscus tear. The operative report documents that the configuration and location of the lateral meniscus tear, in this case, were best suited for partial lateral meniscectomy (CPT 29881).
In addition, the current, peer-reviewed orthopedic literature, including articles published by Kocher and colleagues in the Journal of the American Academy of Orthopedic Surgeons in 2017 and by Lee and associates in the Knee journal in 2016 supports the care that was rendered in this case - specifically a partial lateral meniscectomy for a recurrent tear of a discoid lateral meniscus in a young patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is a young female child. She was transferred to the hospital for diagnosis of acute appendicitis, uncomplicated. She was discharged home the day after surgery.

The inpatient admission was not medically necessary.
The patient could have been cared for at a lower level of care. The patient's leukocytosis was 18 on admission but did not demonstrate any other significant findings on examination, imaging, or operative details that warranted an inpatient level of care. This was a case of uncomplicated acute appendicitis. The patient's condition improved, and she was discharged the day after surgery. The patient's situation did not fulfill any inpatient criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient hospital services
The insurer denied coverage for the inpatient hospital services.
The denial is overturned.

The patient presented to the hospital complaining of chest pain. Past medical history was significant for hypertension, diabetes mellitus, stroke, peripheral vascular disease with bilateral lower extremity amputations, coronary artery bypass graft surgery and end stage renal disease treated on dialysis. Upon arrival to the hospital vital signs were stable: blood pressure 119/53 mmHg (millimeters of mercury), pulse 83 bpm (beats per minute). Physical exam revealed a left sided atrioventricular (AV) fistula and bilateral above the knee amputations. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm with left ventricular hypertrophy. Serum troponin levels were mildly elevated: 0.05ng/ml (nanogram per milliliter). Perfusion stress testing demonstrated lateral wall ischemia. The patient underwent cardiac catheterization that revealed triple vessel coronary artery disease and patent bypass grafts. He was discharged on medical therapy. 

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with chest pain.  His pretest probability of coronary artery disease is high. (1) Utilizing the HEART (history, EKG, age, risk-factors, troponin) score he was considered high risk. (2) Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on EKG was reviewed by Hedayati et al. (3).  Using the HEART score risk stratification schema, this patient would have a high risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge.    

Admission to the hospital to treat an acute cardiac event was medically necessary given the patient's presentation and multiple cardiac risk factors.

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

Diagnosis: Impaired memory, arthritis, headaches and dizziness 
Treatment: Personal Care Aide 7 Days for 12 Hours for a Total of 84 Hours Per Week
The insurer denied: Personal Care Aide 7 Days for 12 Hours for a Total of 84 Hours Per Week
The denial is upheld.

This elderly female is appealing denial of personal care aide seven days, 12 hours, for a total of 84 hours per week.  The plan approved 49 hours per week.  The request for increase was denied because the most recent documentation does not show changes that affect functional or medical needs.
A letter from her provider notes that the patient has multiple chronic medical conditions.  She is dependent on family and home care workers for her activities.  Pain due to arthritis, headaches and dizziness impair her ability to ambulate and complete activities of daily living (ADLs).  She has a history of multiple falls.  She has impaired memory.  An increase in home care hours is recommended.  A progress note has also been provided for review.

The proposed treatment is not medically necessary.
Personal care 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 has multiple chronic medical conditions.  She is appealing denial of personal care aide (PCA) seven days for 12 hours for a total of 84 hours per week.  The plan approved 49 hours per week.  The request for increase was denied because the most recent documentation does not show changes that affect functional or medical needs.  A letter provided by her provider notes that the patient has impaired mobility due to arthritis, headaches and dizziness and recommend an increase in home care hours.  The information provided does to support tasks that require a personal care aide (PCA) 84 hours per week.  Personal care aide is not indicated for management of chronic medical conditions or for supervision.  The proposed increase in personal care worker to 84 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of arthritis, chronic kidney disease stage 3 (CKD3), hyperlipidemia, and recurrent urinary tract infections (UTIs) who was admitted with complaints of (c/o) hematuria, urinary frequency, and dysuria associated with flank pain. She was prescribed antibiotics as an outpatient for a positive urine culture. The vital signs were notable for a blood pressure (BP) of 107/64 and pulse (P) 95. The physical exam was significant for right costovertebral angle (CVA) tenderness, appeared ill. Lab work was notable for a creatinine of 1.9, negative urine culture. A computed tomography (CT) scan of the abdomen/pelvis showed moderate bilateral hydroureteronephrosis. The patient was diagnosed with pyelonephritis and treated with intravenous (IV) antibiotics, pain control and intravenous fluids (IVF). Infectious disease (ID) was consulted and did not feel that infection was a primary cause of the symptoms (due to the negative culture) and that the pain could be from hydroureteronephrosis. Urology evaluated the patient and recommended Pyridium. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o hematuria, urinary frequency, and dysuria associated with flank pain. The patient was hemodynamically stable, did not meet systemic inflammatory response syndrome (SIRS) criteria, did not have acute severe kidney injury, ascending infection, toxic appearance, unstable vital signs, immunosuppression, coexisting urolithiasis, reside in a long-term care facility, did not have diabetes mellitus type 2 (DM2), abnormal anatomy, abscess formation, a single kidney, or kidney transplant. The patient did have a diagnosis of pyelonephritis, but the urine culture was negative and ID evaluation questioned whether the patient had an infection at all, suggesting the pain was secondary to worsening hydroureteronephrosis. Overall, for this patient, there was clinical concern for UTI/pyelonephritis and she was treated with IV antibiotics and Pyridium, with resolution of the symptoms, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Esophagitis.
Treatment:  Procedure code 43239 EGD (esophagogastroduodenoscopy).

The insurer denied coverage for procedure code 43239 EGD (esophagogastroduodenoscopy).  The denial is upheld.

The patient was complaining of epigastric burning for a month. The day before the visit she went to the ER (emergency room) and was given Pepcid. She was also taking Mylanta. An endoscopy was scheduled. Mild esophagitis and gastritis were found. No H. (Helicobacter) Pylori or intestinal metaplasia was found. 

Clinical indications for doing an Upper GI (gastrointestinal) Endoscopy are listed in MCG (Milliman Care Guidelines) ACG: A-0203. Dyspepsia is an indication if the patient is 60 years old or more, if there is a failure of medical therapy with a H (histamine) 2 blocker or a PPI (proton pump inhibitor), a family history of upper GI cancer, iron deficiency anemia, a long history of symptoms, or weight loss. The patient did not have these conditions. Gastroesophageal reflux is also an indication for endoscopy, if there is anemia, dysphagia, failure of medical therapy with a PPI, recurrent vomiting, or weight loss. The patient did not have these conditions.

This patient had upper abdominal pain. She did not have a sufficient trial of a H2 blocker or PPI. The Pepcid was started only one day prior to the scheduling of the endoscopy. She did not meet MCG criteria for doing an endoscopy either for dyspepsia or gastroesophageal reflux. The health care plan acted reasonably and with sound medical judgment. Doing an endoscopy was not medically necessary. The denial is upheld.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for procedure code 43239 (EGD) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dilated aortic root
Treatment: Magnetic Resonance Imaging (MRI) of the Pelvis with and without Contrast Dye

The insurer denied Magnetic Resonance Imaging (MRI) of the Pelvis with and without Contrast Dye. The health plan's determination is upheld.

The patient is a male with history of non-ischemic cardiomyopathy, implantable cardioverter defibrillator (ICD), dilated aortic root, hypertension, hyperlipidemia, and kidney disease. Echocardiography demonstrated a dilated aortic root. A recent Echocardiography demonstrated a dilated aortic root. A Cardiac magnetic resonance imaging (MRI) to evaluate the dilated aortic root is under review.

The Magnetic Resonance Imaging (MRI) of the Pelvis with and without Contrast Dye is not medically necessary for this patient.

This individual had serial echocardiograms demonstrating a dilated aortic root. There are various imaging modalities to evaluate the aortic root. These include echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). In the setting of this case, a MRI, compared to for example serial echocardiograms, has not been established instead of care towards definitively improved aorta outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dilated aortic root
Treatment: Magnetic Resonance Imaging (MRI) of the Pelvis with and without Contrast Dye
The insurer denied Magnetic Resonance Imaging (MRI) of the Pelvis with and without Contrast Dye. The health plan's determination is upheld.

The patient is a male with history of non-ischemic cardiomyopathy, implantable cardioverter defibrillator (ICD), dilated aortic root, hypertension, hyperlipidemia, and kidney disease. Echocardiography demonstrated a dilated aortic root. A recent Echocardiography demonstrated a dilated aortic root. A Cardiac magnetic resonance imaging (MRI) to evaluate the dilated aortic root is under review.

The Magnetic Resonance Imaging (MRI) of the Pelvis with and without Contrast Dye is not medically necessary for this patient.
This individual had cereal echocardiograms demonstrating a dilated aortic root. There are various imaging modalities to evaluate the aortic root. These include echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). In the setting of this case, a MRI, compared to for example serial echocardiograms, has not been established instead of care towards definitively improved aorta outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult female with pulmonary hypertension, chronic obstructive pulmonary disorder (COPD), deep vein thrombosis (DVT), and scleroderma with worsening shortness of breath who was found to have severe anemia. The patient was admitted to acute hospitalization for the management of anemia. The patient received a blood transfusion. The patient was seen by hematology as well as gastroenterology. 
The patient was admitted to acute in hospital level of care. This hospitalization was denied due to lack of medical necessity. This denial is being appealed. 

The proposed inpatient hospital admission was medically necessary. 
This patient has multiple medical problems including chronic respiratory failure due to chronic obstructive pulmonary disease (COPD) and pulmonary arterial hypertension who had worsening shortness breath of breath (SOB) due to anemia as well as acute exacerbation of chronic obstructive pulmonary disease and pulmonary hypertension. Despite emergency room care and blood transfusion, the patient continued to have shortness of breath and slow response to blood transfusion. The requested hospitalization was medically necessary. 

Given that the patient's signs and symptoms did not improve with emergency room care and the patient had significant comorbid conditions, it would not have been reasonable to expect significant improvement within 24 to 48 hours, as is what happened with the patient. The patient's treatment course would have been expected to require treatments or interventions that could not have been provided at a lower level of care. The requested hospitalization is medically necessary.