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


Diagnosis: hemophilia A.
Treatment: Emicizumab-kxwh 105 MG/0.7ML Subcutaneous Solution (Hemlibra)
The insurer denied Emicizumab-kxwh 105 MG/0.7ML Subcutaneous Solution (Hemlibra)
The health plan's determination is overturned.

The patient is a young male with severe hemophilia A. He has been receiving treatment with Hemlibra. He currently has some functional limitations in the bilateral elbows and left ankle, related to pain, but this does not affect his independence. His dosing recently increased, based on his weight, and his provider is recommending that he use the 105 milligrams (mg) per 0.7 milliliter (mL) Hemlibra vial, 1 injection of 0.45 mL once per week, for his treatment. 

Emicizumab-kxwh 105 MG/0.7ML Subcutaneous Solution (Hemlibra) is medically necessary for this patient.
This patient has a diagnosis of severe hemophilia A, requiring treatment with Hemlibra.
There is literature discussing issues with noncompliance in the treatment of hemophilia patients. Noncompliance is a significant issue for these individuals, are typically far fewer than one-half of patients are fully compliant with treatment recommendations. Noncompliance with any aspect of her protocol therapy is associated with mortality, including medical consultation, clotting factor regimens, and serological tests. The majority of deaths are noted to be due to bleeding. Multiple studies looking at the clotting factor regimen specifically have noted compliance rates of anywhere from 43% to 65%. Adherence is better for those who have parental administration of the product. Compliance issues with clotting factor therapy may be influenced by clinical, personal, social, and organizational factors. In this instance, the physician is specifically concerned about noncompliance for this teenage patient who will have to go from 1 shot per week to 2 shots per week based on the vial selected for dosing. While the higher volume vial is less cost-efficient, it is more likely to result in better compliance with the clotting regimen, and therefore we will be more likely to result in less morbidity and potentially mortality for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Advanced Anal Cancer.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with locally advanced anal cancer. The patient presented to the hospital with rectal pain, fatigue, suicidal thoughts, and inability to tolerate oral intake and medications. He was on his way to outpatient treatment but experienced a syncopal episode and was directed to their emergency room where he was admitted for inpatient care. The patient was noted to be moderately malnourished with severe weight loss and severely decreased energy resulting in impaired performance status.
While hospitalized, the patient underwent a sigmoidoscopy with incision and drainage of an ischiorectal abscess with fistulectomy. On exam, a diffuse necrotic tumor was noted. Throughout the hospitalization, the patient received supportive care, pain management, nutrition, and palliative care.
The patient was discharged to hospice; inpatient care is under review for medical necessity.
The inpatient hospital admission was not medically necessary.
This patient received supportive care throughout his hospitalization. The patient was hemodynamically stable and with uncontrolled pain at the time of admission. At the time of admission, the patient received nutrition, palliative care, psychosocial support, intravenous (IV) fluids, and analgesia (transdermal and oral). The patient did not require intensive nursing care nor intravenous therapies that required the inpatient level of care. No other interventions were provided that required the inpatient level of care and a substantial amount of the inpatient care appears to have been related to arranging a disposition. Support for inpatient level of care based on the provided services is not present in the peer-reviewed literature nor national guidelines. For these reasons, medical necessity for inpatient care cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal bleed
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns of bright red blood per rectum for several week duration. Pertinent history included recurrent lower gastrointestinal bleeding, sigmoid and rectal arteriovenous malformation, and chronic iron deficiency anemia. Initial vital signs revealed a temperature of 97.9 degrees Fahrenheit, heart rate (HR) 91, blood pressure (BP) 109/75, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 100% (percent) on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell (WBC) count 8.1, Hemoglobin (Hgb) 8.6, platelets (Plt) 408, Na (sodium) 141, K (potassium) 4.0, blood urea nitrogen (BUN) 12, Cr (creatinine) 0.93, and Glucose 91. The patient was placed in the hospital thereafter with an impression of rectal bleeding and microcytic anemia likely due to chronic blood loss. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a history of chronic lower gastrointestinal bleeding and associated anemia who presented with rectal bleeding of several week duration. Initial evaluation documented the patient as alert, oriented, hemodynamically stable, and with a Hgb 8.6. Treatment included serial Hgb checks and a gastroenterology consultation. An esophagogastroduodenoscopy (EGD) and colonoscopy were performed without high-risk findings or active bleeding. Diet was advanced, no continued bleeding was noted, and a transfusion of blood products was not needed. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral vascular accident
Treatment: home health care
The insurer denied Personal Care Assistance Services: 84 Hours per Week 
The health plan's determination is overturned. 

This is an elderly female patient with a history of right-sided hemiplegia and hemiparesis due to a cerebrovascular disease, diabetes mellitus, heart failure, muscle weakness, and osteoarthritis of multiple joints. She experienced a fall in which she fell off a chair she was standing on to reach something; she did not seek medical care after this fall. The patient and her care team are requesting 84 hours per week of PCA (personal care assistant) services.

PCA services 84 hours a week is medically necessary for the patient. There is documentation in the recent Uniform Assessment System (UAS) of the patient requiring at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of medical necessity of increased PCA services. The patient does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient was sent the emergency room (ER) from urgent care due to complaints of severe headache, blurred vision, and nausea since Thursday. Upon arrival her vital signs were Temperature-97.7 degrees F, Heart rate-82, Respirations-18, oxygen (O2) saturation-100%, and Blood pressure-179/120. She rates her headache an 8/10. Computed tomography (CT) completed and labs drawn. She was medicated with Hydralazine 5 milligrams (mg) intravenous (IV) push. She admits to noncompliance with her blood pressure medication but did take them yesterday and today. She was seen at this facility two times last year with similar complaints related to uncontrolled hypertension. Troponin-0.02. CT noted no acute intracranial hemorrhage. X-Ray noted no acute radiographic cardiopulmonary disease. Electrocardiogram (EKG) noted normal sinus rhythm. The patient continued to complain of headache, dizziness, lightheadedness, and generalized body aches. Plan for additional dose of hydralazine, Tylenol for pain, and Valium for muscle relaxation. Due to concerns with accelerated hypertension, headache/lightheadedness, patient will be admitted for further workup and management of her symptoms. Treatment plan related to hypertensive emergency. The record indicates patient received multiple doses of Hydralazine along with Norvasc with improvement noted in the blood pressure-164/105. 

Evidence based literature notes that the American College of Emergency Physicians currently recommends initiation of therapy in the emergency department only for selected patients who are likely to have poor follow-up. Patients without target-organ damage are usually asymptomatic. Symptoms, when present, may include headache, atypical chest pain, dyspnea, dizziness, lightheadedness, and epistaxis. For patients with symptoms that are presumed to relate to hypertension but are not indicative of target-organ damage (e.g., headache, atypical chest pain, or epistaxis), it is reasonable to choose an oral agent with a faster onset of action. 

The review of the hospital admission and the guidelines for hospital admission related to hypertensive emergency indicate this patient, although no evidence of new or worsening target organ damage, needed to be admitted due to her severe blood pressures and persistent severe headache that were not improving. As such the admission was medically necessary.

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: Overturned

Diagnosis: Left main coronary artery stenosis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is the case of a gentleman that presented to the hospital for elective cardiac catheterization after complaining of recurrent palpitations and lightheadedness. Past medical history was significant for frequent ventricular ectopy on electrocardiogram, hypertension, hypercholesterolemia, and diabetes mellitus. Results revealed a severe ostial left main coronary artery stenosis and a left ventricular ejection fraction of 50% (percent). The patient remained hospitalized until transferred to a tertiary care center for revascularization. 

This patient presented with crescendo symptoms of palpitations and lightheadedness. His pretest probability of coronary artery disease was intermediate. [1] This patient was noted to have a severe ostial stenosis of the left main coronary artery. Several studies have demonstrated that patients requiring circulatory support, multivessel revascularization, and left main coronary artery revascularization are considered high risk and cannot be managed at lower levels of care. [2-5] Inpatient admission for monitoring and treatment was medically necessary. In conclusion, inpatient admission to the hospital was medically necessary.

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

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, depression, glaucoma, hypertension, hyperlipidemia, coronary artery disease, and osteoarthritis
Treatment: Increase Home/Personal Care Level 2 Per 15minutes to 24 Hours Per Day (live in)
The insurer denied: Increase Home/Personal Care Level 2 Per 15minutes to 24 Hours Per Day (live in)
The denial is overturned.

The Increase Home/Personal Care Level 2 Per 15minutes to 24 Hours Per Day (live in) 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. Denial of increase home/personal care services to 24 hours per day (live in) is being appealed. The health plan approved 36 hours per week. This patient has multiple chronic conditions, including recent hospitalization due to falls and 
mental status change. Uniform Assessment System (UAS) evaluation completed 5 months ago shows she requires assistance with all activities of daily livings, except eating. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed 5 months ago, there has been a decline in her functional status. Appeal statements and medical records support the patient's needs for assistance with all activities of daily living. The approved personal care services of 36 hours per week is insufficient to meet the patient's needs for assistance with all activities of daily living. There has been a significant decline in the patient's level of functioning between UAS (uniform assessment system) evaluations. The requested increase to 24 hours per day (live in) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic lung disease, bilateral cystic periventricular leukomalacia. 
Treatment: Continued Acute Rehabilitation (rehab) Stay. 
The insurer denied: Continued Acute Rehabilitation Stay. 
The denial is overturned. 

This is a toddler male child with complex medical conditions. The child had been born at 24 weeks, required neonatal intensive care unit (NICU) stay. The child has a history of chronic lung disease. The child has required multiple intubations. Neurologically, the child had developed bilateral cystic periventricular leukomalacia. Magnetic resonance image (MRI) revealed encephalomalacia and gliosis of the left paramedian parietal lobe. The child is dependent on gastrostomy tube (GT) alimentation. The child had renal hypertension that is being controlled by antihypertensive medications. The child has a tracheostomy. Clinical and rehabilitative/habilitative interventions have been provided at the acute level of care. Overall, the child received 111 days of acute inpatient rehabilitative care. Additional care has been requested at the acute level of care; however, following review by the insurance plan, the denial has been upheld. The purpose of this review to review the appeal and determine if further stay in acute inpatient rehabilitation is medically necessary. 

The requested health service is medically necessary. 

In this case, this child with complex medical conditions continues to receive specialized medical and rehabilitative care. The child is not safe to be discharged or moved to a lower level of care. 
The health plan did not take into account the medical fragility of this child. This child has recently been extubated and continues to exhibit signs of periodic distress requiring redirection, treatment and behavioral aberrations. Additional work up to 6 weeks may be medically necessary for establishment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malpositioned Teeth
Treatment: Braces and Monthly Visits (x[times]12)
The health plan denied: Braces and Monthly Visits (x12)
The determination is: Overturned

The patient is a male with a class II malocclusion with protrusive maxillary incisors. He has a 7 millimeter (mm) overjet and a 5 mm deep bite. He has moderate maxillary and mandibular crowding. He is planned for orthodontics to correct this malocclusion.

The braces and monthly visits (x12) are medically necessary for this patient. Teeth 8 and 9 are protruding forward within the dental arch, making them more prone to trauma. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, overjets greater than 6 mm are shown to negatively affect the oral health quality of life of patients. For these reasons, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain. 
Treatment: Inpatient hospital stay. 
The insurer denied the inpatient hospital stay. 
The health plan's determination is overturned. 

The patient is a female with past medical history (PMH) of sickle cell disease (SCD) who was admitted with complaints of (c/o) abdominal pain and dark urine. Vital signs were notable for T (temperature) 100.1, and pulse 90. Physical exam was notable for no acute distress, and right upper quadrant (RUQ) tenderness to palpation (TTP). Lab work was notable for leukocytosis, hemoglobin 8.9, transaminitis, and elevated bilirubin. A POCUS (point of care ultrasound) of the liver showed no acute disease. A computed tomography (CT) A/P (abdomen/pelvis) showed mild periportal edema, magnetic resonance cholangiopancreatography (MRCP) showed no evidence of choledocholithiasis. The patient was diagnosed with sickle cell crisis and possible acute cholangitis. 

The inpatient hospital stay was medically necessary. This patient presented to the emergency department (ED) with c/o abdominal pain and dark urine. The patient was initially diagnosed with sickle cell crisis, however, due to the pattern of laboratory findings consistent with biliary obstruction and evidence of sepsis with tachycardia and significant leukocytosis, there was high clinical suspicion for sepsis secondary to acute cholangitis. The patient was evaluated by GI (gastroenterology), who felt that there was high enough clinical suspicion for sepsis secondary to acute cholangitis to warrant continued antibiotics and MRCP, which did not demonstrate any stones in the common bile duct (CBD), although it was theorized that a stone has already passes given the improvement in the patient's laboratory findings. Given the high clinical suspicion for acute cholangitis, this patient required close clinical monitoring for complications such as acute pancreatitis, hepatic abscess, worsening sepsis, hepatic dysfunction, bile peritonitis, portal vein thrombosis, and gallstone ileus, while receiving broad-spectrum antibiotics in anticipation of possible acute surgical intervention. All patients with suspected acute cholangitis should be admitted with immediate surgical and GI consultation, especially in a patient with acute sickle cell crisis and fever.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Bleeding (Status post (s/p) pregnancy loss)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the emergency department with vaginal bleeding and abdominal pain. She had a recent vacuum dilatation & curettage (D&C) for an eight-week pregnancy abortion. The patient had stable vital signs. Her exam revealed abdominal pain and brisk blood in the vaginal vault. She had blood work revealing mild anemia and an elevated white blood cell count. She had a pelvic ultrasound and computed tomography (CT) scan that were negative. Gynecology was consulted. The patient was given tranexamic acid, misoprostol, and intravenous Zosyn. She received Toradol, Tylenol, and oxycodone for pain. She improved and was discharged home on seven days of doxycycline. Her hemoglobin was 11.5. The inpatient admission was denied coverage by the health plan as not medically necessary. This is being appealed.

The inpatient admission was not medically necessary.

An outpatient observation bed is an alternate level of healthcare composed of short-stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.
In review of the medical record, the patient presented with vaginal bleeding and abdominal pain. She was hemodynamically stable, and imaging did not reveal any acute findings. She was given medications in the emergency department to help with the pain and bleeding. She improved within 24 hours and was able to be discharged home. Although she required close monitoring including pain medication, there were no acute issues identified. An inpatient level of care was not necessary. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Vein Thrombosis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

This case involves a man with stage IV lung cancer, metastatic to the brain, currently undergoing chemotherapy and completed radiation therapy to the brain, who presented to the hospital, and was admitted with bilateral lower extremity swelling. The patient ran out of medications for three weeks, including torsemide. 

Inpatient admission was medically necessary.
The patient was admitted with bilateral lower extremity edema, with no evidence of cardiac, renal, or liver dysfunction to account for the swelling. Bilateral gastrocnemius vein DVTs (deep vein thrombosis) were discovered on vascular imaging, deemed to be acute, and developing in the setting of anticoagulation with a direct oral anticoagulant. As a result, the patient was admitted to an inpatient level of care to initiate alternative treatments. Milliman and InterQual criteria recognize the need for inpatient admission for failure of anticoagulation therapy.
Furthermore, the development of cerebral bleeding is an indication for inpatient admission. As noted in the documentation, the patient suffered a fall and has developed a subdural, subarachnoid hemorrhage, which fortunately did not require surgical intervention. Still, nevertheless, the intensity of services provided around monitoring for stability qualifies for an inpatient stay. Additionally, the patient has a history of malignancy, has received radiation to the brain, and is currently undergoing active chemotherapy treatment. These risk factors provide a high complexity presentation, which cannot be managed at a lower level of care.