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

Diagnosis: Foot Pain and Foot Abnormality. 
Treatment: Durable Medical Equipment (custom shoe inserts L3000 x 2). 
The insurer denied:  Durable Medical Equipment (custom shoe inserts L3000 x 2). 
The denial is upheld. 

The patient is an adult female with complaints of bilateral foot pain. The diagnosis provided in the appeal letter indicates plantar fasciitis. The patient has tried OTC (over the counter) orthotics without success in relieving symptoms. Per a doctor's note, the patient presented with a chief complaint of knee pain. No mention of plantar fasciitis is made. Per another doctor's note, the patient presented with chief complaint of right knee and shoulder pain. Diagnoses of hammertoes, blister, and hyperhidrosis are noted. No mention of plantar fasciitis is made. 
Per a doctor's note a week later, the patient presented with chief complaint of blisters. Diagnoses of foot pronation and bilateral calcaneovalgus deformity. No mention of plantar fasciitis is made. Per a doctor's note one month later, the patient presented as a follow-up visit for arch pain. The final diagnosis given is bilateral calcaneovalgus and arch pain. There is note in medication section of OTC (over the counter) orthotics with diagnosis of M72.2, which is plantar fibromatosis. This is used for diagnosis of plantar fasciitis. This is first time M72.2 is documented as a diagnosis, but for justification of OTC (over the counter) orthotics. However, plantar fasciitis is not documented in the final diagnosis. The note documents a recommendation for the patient to ease into OTC (over the counter) orthotics. 

The requested health service is not medically necessary. 

MCG (Milliman Care Guidelines) criteria are not met. The criteria require diagnosis of plantar fasciitis to be present for at least three months. The standard is also that the diagnosis must be documented in the medical records, and not just in appeal letters. The first documented diagnosis of M72.2 (plantar fibromatosis) is in a later medication note. It is not in the diagnosis section. There is no documentation that the patient has failed three months of conservative care, including OTC (over the counter) orthotics. The appeal letter is dated less than one month after the first documented note involving the diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has diabetes and presented with right upper quadrant (RUQ) abdominal pain. The patient was scheduled to have a cholecystectomy 2 weeks later but came to the emergency room (ER). The patient was afebrile and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. A sonogram showed extensive cholelithiasis but not acute cholecystitis. The patient underwent a laparoscopic cholecystectomy. The chart reports that she tolerated the procedure well and no complications were reported. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-555 for Gallbladder or Bile Duct Inflammation or Obstruction. Clinical indications for admission include having acute cholecystitis as manifested by pain and systemic signs of inflammation. This patient had gallbladder disease but the sonogram did not show acute cholecystitis. In addition, she did not have systemic signs of inflammation such as fever or leukocytosis. The patient did not have acute cholangitis. The patient also did not have hemodynamic instability, common bile duct obstruction, severe vomiting, severe pain unresponsive to medications, or bacteremia. 

This patient had biliary colic and required a laparoscopic cholecystectomy. The patient remained stable to have had this performed as ambulatory surgery. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. 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 an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever, upper respiratory infection (URI) symptoms.
Treatment:  Inpatient stay.

The insurer denied an inpatient stay.  The health plan's determination is upheld. 

The patient is a young female brought to the emergency department with two days of fever, upper respiratory infection (URI) symptoms, abdominal discomfort, decreased urine, and decreased oral intake. There was no vomiting or diarrhea. The patient had been seen the day before in a different emergency department and was told the child had a viral illness. The patient was febrile to 104.4. Exam was normal and commented on moist mucus membranes and normal capillary refill. Viral panel was positive for adenovirus. Abdominal ultrasound was normal. The patient was given two normal saline boluses in the emergency department and admitted to the pediatric ward for further care. 

Inpatient Hospital Admission was not medically necessary for this patient.

The patient was diagnosed in the emergency department with adenovirus infection, which explained the fever and upper respiratory symptoms. She had received a diagnosis of viral infection in a different emergency department the day before. She did not appear toxic and did not require intravenous antibiotics. She was admitted for hydration in the setting of decreased oral intake with the illness, but she was at most mildly "dry" upon presentation with a bicarbonate of 18. Clinically, she was not dehydrated; mucus membranes were moist. While she was taking less orally than normal, after receiving two normal saline boluses in the emergency department, she was certainly fully fluid repleted by the time she arrived on the pediatric ward. She did not require acute inpatient care for either the infection or for further intravenous fluid. Instead, she could have been discharged home with close outpatient follow up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left leg pain
Treatment: Vascular Surgery (35656 x 1), Bypass graft, with
other than vein
The insurer denied: Vascular Surgery (35656 x 1), Bypass graft, with other than vein
The denial is upheld.

The patient is an adult male. He is being evaluated for ongoing left leg claudication. The patient is status post left to right cross-over fem-fem bypass graft. As of a clinic note dated last month, the patient is still smoking. 

The requested health service is not medically necessary.

This patient is noted to have left leg claudication symptoms. As per the MCG (Milliman Care Guidelines) Guidelines: Femoral Popliteal Bypass ORG: S-480 (ISC) MCG (1), as well as according to the medical literature cited below, the appropriate the treatment of claudication as requested for this patient, which would be in accordance with generally accepted standards of medical practice, includes at least significant functional or lifestyle-altering impairment from pain despite maximally tolerated non-operative therapy (e.g., medication, smoking cessation, exercise program: usually 3 to 6 months). This is not met in this case. The patient's specific limitation of ADLs (activities of daily living) is not documented. A physician-monitored trial of conservative therapy is not documented. Importantly, even after being treated for very significant peripheral arterial disease, this patient continues to smoke. This patient continues to smoke without any well-documented trial of conservative therapy. Importantly, it is documented that his patient has "Mild or moderate disease that does not limit activities." Surgery may be avoided with smoking cessation and conservative therapy. Ongoing smoking is associated with accelerating graft failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure Disorder, Prior Stroke, Memory Impairment
Treatment: Personal Care HHC Level 2 Personal Care Services, per 15 minutes increase to 49 hours per week 
The insurer denied Personal Care HHC Level 2 Personal Care Services, per 15 minutes increase to 49 hours per week.
The determination is upheld.

This is a female patient with a medical history notable for a seizure disorder, prior stroke, and memory impairment. The patient is approved for 40 hours per week of home care personal care services. The patient and her care team requested an increase to 49 hours per week, and the request was denied by the health plan.
The patient's case manager provided a letter of support. The letter states that the patient is not safe for long periods without supervision. She is not able to ambulate outside of the home without assistance. She also requires help with shopping, cleaning, laundry, dressing bathing, mobility, and hygiene.
A Uniform Assessment System (UAS) was completed. The patient lives alone in her apartment. She was alert and oriented with periods of forgetfulness. She is able to direct her own care and call for help in an emergency. For her Instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation, housework, stairs, and shopping. She requires extensive assistance for finances, medications, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing. She requires limited assistance for hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility and eating. She is occasionally incontinent of urine and stool (less than daily). A task tool associated with the UAS recommended 37.33 hours per week to address her personal care needs. Compared to a prior assessment, she showed a stable level of function. At issue is the medical necessity of Personal Care HHC Level 2 Personal Care Services, per 15 minutes increase to 49 hours per week.

The requested health service of Personal Care HHC Level 2 Personal Care Services, per 15 minutes increase to 49 hours per week has not been demonstrated to be medically necessary for this patient.
The patient currently receives 40 hours per week, which is 3 hours more than recommended by the UAS task tool. Her most recent UAS did not show any significant worsening of her functional status. There is no documentation regarding which personal care needs, if any, are not being met with her current allotment of hours. The tasks that her social worker requested assistance with were noted by the UAS and accounted for by the task tool. Personal care aide hours cannot be granted for safety monitoring and supervision. The provided documents do not demonstrate that the patient's personal care needs are not being met. Therefore, the requested increase from 40 to 49 hours per week has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronavirus disease (COVID) 19
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

This is a female patient with a history of asthma. Her presenting complaints were a cough, fever, and dyspnea, and hypoxia to the 80s at home per the patient. The physical exam was notable for wheezing. Lab results were notable for a coronavirus disease (COVID) 19 positive test. Radiology was unremarkable. In the emergency department (ED), the patient received steroids, nebulizer therapy, and was admitted to an inpatient level of care for treatment of an asthma exacerbation triggered by COVID19. At issue is the medical necessity of an inpatient stay.
The inpatient admission was medically necessary for this patient.
The patient presented with a cough and dyspnea along with tachycardia and reported hypoxia at home, and was found to have a COVID 19 infection. She was diagnosed with an acute asthma exacerbation triggered by COVID 19. COVID 19 can be a fatal disease in people with asthma, and rapid evaluation and management is crucial in preventing adverse outcomes. The patient needed intravenous (IV) Remdesivir in addition to steroids and nebulizer therapy. An inpatient level of care was medically necessary to provide this for her, and a lower level of care would not have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Arm and Leg Weakness.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of conversion disorder who presented to the hospital for evaluation of bilateral arm and leg weakness. The patient underwent imaging which did not show an acute neurologic process. The patient was evaluated by neurology who did not recommend any further workup. The patient's signs and symptoms were attributed to conversion disorder. The patient was evaluated by psychiatry and underwent medication management. Inpatient behavioral health hospitalization was not recommended. The patient was subsequently discharged from the hospital for rehabilitation placement. At issue is the medical necessity of an inpatient hospitalization stay.

Acute inpatient hospitalization is not medically necessary. The patient presented to the hospital with arm and leg weakness. The patient has a known history of conversion disorder. The patient had signs and symptoms attributed to conversion disorder. The patient did not have an acute neurologic process. She did not have any abnormal neurologic imaging. The patient was evaluated by psychiatry and underwent medication management but there was not a need for acute behavioral health hospitalization. During the hospitalization, the patient did not have any significant abnormal vital signs or laboratory imaging. None of the care provided met the severity for an acute inpatient hospitalization. As such, the inpatient stay was not medically necessary, and the signs and symptoms could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a male with medical history notable for schizophrenia and substance abuse. The patient presented to the hospital complaining of back pain and left foot pain after a possible spider bite. He denied fevers or systemic symptoms. His white blood cell (WBC) count was normal. Potassium was 3.2. He had normal x-rays. He was diagnosed with an abscess and admitted to the hospital for further care.

The requested Inpatient Hospital Admission was not medically necessary for this patient. He could have been safely treated at a lower level of care.
The patient presented with signs and symptoms of an abscess. He did not have any fevers, elevated white blood cell count, or signs of systemic toxicity. He was treated with antibiotics and local wound care and showed good improvement. He did not fail outpatient therapy or show worsening with initial antibiotic therapy. Due to his unstable living situation, monitoring in the hospital was medically appropriate. However, the patient did not meet the medical necessity for inpatient admission. He could have been appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: High intensity-focused ultrasound (HIFU) ablation 
The insurer denied high intensity-focused ultrasound (HIFU) ablation.
The determination is upheld.

This is a male patient with a favorable intermediate risk prostate cancer (Gleason 3+4=7) who has requested coverage for prostate high intensity-focused ultrasound (HIFU), including ultrasound guidance. The patient's prostate-specific antigen (PSA) was 4.  He is to have a transurethral resection of the prostate (TURP) 1 month prior to HIFU.  He underwent a prior HIFU ablation with apparent initial success, but a recent confirmatory prostate biopsy revealed a small area of residual disease. At issue is the medical necessity of the requested high intensity-focused ultrasound (HIFU) ablation. 

No. The high intensity-focused ultrasound (HIFU) ablation is not medically necessary. The patient has a favorable intermediate risk prostate cancer (Gleason 3+4=7)
Per the American Urological Association (AUA) Guidelines,
12. For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. (Strong Recommendation; Evidence Level: Grade A)
"13. Clinicians should inform patients with intermediate-risk prostate cancer considering whole gland or focal ablation that there is a lack of high-quality data comparing ablation outcomes to radiation therapy, surgery, and active surveillance. (Expert Opinion)."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a female patient without a significant past medical history who presented to the emergency room (ER) with abdominal pain of 3 week's duration. She was hemodynamically stable and afebrile. She had diffuse left lower quadrant tenderness without rebound guarding or rigidity. She had mild leukocytosis but the rest of her labs were unremarkable. She had a computed tomography (CT) scan showing acute uncomplicated diverticulitis in the descending colon. She was admitted as an inpatient for continued care and was started on intravenous (IV) antibiotics, IV fluids and analgesics. Her abdominal pain gradually resolved, her diet was advanced, and she was discharged to home with outpatient follow up. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital stay is not medically necessary for this patient. The patient could have been safely and effectively managed at a lower level of care.

Factors that would have warranted an inpatient level of stay would have been prolonged nothing by mouth (NPO) status, severe pain requiring IV analgesia, surgical intervention. Review of the medical records provided indicate that this patent had acute uncomplicated diverticulitis. There is no documentation of hemodynamically instability, no evidence of systemic inflammatory response syndrome (SIRS) or sepsis, nor did she have evidence of peritonitis to warrant acute level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Avascular Necrosis

Treatment: Long term care placement 

The insurer denied coverage for long term care placement

The denial is upheld

This is a patient with chronic medical problems including avascular necrosis, neuropathy and depression. The patient was transferred from the Skilled Nursing Facility (SNF) to the hospital, for scheduled hip surgery. Under review is the medical necessity for long term care placement.

The patient's clinical condition and functional ability are not at a level as to require long term care for the time period under review. The patient was essentially modified independent for activities of daily living and functional mobility. The patient ambulates approximately 150 with a rolling walker. There were no acute medical or complicated nursing issues. The clinical records do not document a level of care that requires long term (facility) care. The patient could have been discharged home with visiting nursing services as necessary. 

The health 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, 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, long term care placement 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 long term care placement is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness with headache

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult female who presented to the emergency department with complaints of dizziness with headache, beginning one hour previously. She complained of spinning, dizziness, and also had cervical spine pain. She complained of intermittent right sided chest discomfort. Acute myocardial infarction was ruled out with troponins. A head computerized tomography (CT) scan performed on presentation revealed no acute abnormality. Her blood pressure was controlled. Laboratory testing was unremarkable. Head computerized tomography (CT) scan and cervical and brain Magnetic Resonance (MR) angiography were negative. She was seen by neurology who recommended laboratory testing and a brain Magnetic Resonance Imaging (MRI) which was negative for acute stroke. 

The patient presented with complaints of dizziness and headaches, with the headache being described as moderate. She had a prior history of hypertension, diabetes, anxiety, gastroesophageal reflux, cardiac catheterization, retinal detachment and right total knee replacement. Pertinent medications were amlodipine, metformin, omeprazole, and tramadol. Blood pressure was slightly elevated at 162/96 mmHg (millimeters of mercury). She had high-risk comorbidities, and was admitted for close hemodynamic and neurological monitoring, continuous pulse oximetry and hourly neuro-checks.  It was noted that headaches of any type could be symptomatic of an underlying process. There was no documentation that the patient had a headache such as a thunderclap headache that would require urgent inpatient care.

Myocardial infarction was excluded with troponins. A head computerized tomography (CT) scan excluded a visible structural lesion. Computerized tomography (CT) angiography of the head and neck excluded vascular anomalies or vascular stenosis. Brain Magnetic Resonance Imaging (MRI) was negative for acute stroke.

The patient had a mildly increased blood pressure but not the level that could precipitate her symptoms, and at a level that can be controlled with oral medications on a non-inpatient basis. There is no evidence of hypotension. There is no change in mental status. There is no evidence of seizures. There is no evidence of symptoms of an intracranial bleed, such as a subarachnoid hemorrhage. There is no evidence of any need for a high level of cardiac, hemodynamic, or pulmonary care. There is no expectation of worsening of her symptoms given their stability. 

There is no specific medical necessity for acute inpatient hospitalization as the patient could have been treated in the emergency department or observation setting, with discharge once stroke, other structural lesions and myocardial infarction were ruled out.

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.