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

Diagnosis: Possible bilateral hand cellulitis versus a contact dermatitis.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a male patient with past medical history significant for asthma who presented to the Emergency Department (ED) with complaints of bilateral hand rash and peeling of skin.  Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 123/70, Pulse 105, Respiratory Rate 18, and Oxygen (O2) saturation 100% on Room Air.  Laboratory results included the following; white blood cell (WBC) count 11.5, hemoglobin (HGB) 14.9, hematocrit (HCT) 45.5, creatinine 0.95, and glucose 101.

The patient was admitted with a possible bilateral hand cellulitis versus a contact dermatitis.  He was empirically started on intravenous (IV) antibiotics (vancomycin and ceftriaxone).  Infectious Diseases (ID) consulted and documented -"minimal if any cellulitis...uggests Dermatology consult for topical treatment." ID recommended discontinuation of systemic antibiotics.  Dermatology evaluated patient and recommended topical ointments including clobetasol, triamcinolone, and to follow-up as outpatient.  The patient remained afebrile, and hemodynamically stable.  He was discharged to continue outpatient management.

According to documentation, the patient presented with bilateral hand allergic reaction.  The patient was otherwise afebrile, hemodynamically with a mildly elevated white blood cell (WBC) count that normalized while in the ED. 

Admission note documents-"there is no fever/significant leukocytosis, no signs of sepsis...  ID deemed antibiotics were not necessary and Dermatology recommended topical ointments for contact dermatitis.  Based on above findings, the patient did not meet criteria for acute care hospitalization.  

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

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

Diagnosis: Fever, nasal congestion, poor oral intake, diarrhea, heavy breathing, increased irritability.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This patient is a female child who presented to the Emergency Department (ED) for a 3 day history of fever, nasal congestion, poor oral intake, diarrhea, heavy breathing, increased irritability, and more crying. On examination, there was nasal congestion, rhinorrhea, Oropharyngeal exudates with posterior oropharyngeal erythema, temperature 102 degrees Fahrenheit and moderate tachycardia.  In the ED the patient received intravenous (IV) fluids, IV antibiotics, and Tylenol. 

Although it is stated in the appeal letter that "Upon serial monitoring, the patient continued to have poor oral intake, consistent with failure to achieve symptom improvement and further supporting the necessity of acute inpatient care," there is no documentation in the ED notes to support this, even though the patient was in the ED for 6 hours prior to admission, during which time, success or failure (such as vomiting) of oral (PO) hydration can be documented.  Also, there was no objective evidence of bacterial sepsis.  There were no "severe constitutional symptoms" or "immunocompromised state." The patient was non-toxic appearing.  The patient's white blood cell (WBC) count and differential counts were normal and did not point to a bacterial infection, and antibiotics were not warranted per current standards of practice. 

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

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

Diagnosis: Left inguinal hernia.
Treatment: Inpatient admission.

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

The patient is a male. His medical history included schizophrenia and bipolar disorder (with a history of hallucinations/delusions/psychoses and pharmacologic non-compliance); overweight/obesity; and tobacco use. Despite "no emergency complaints," he was, "sent in for pre-op admission as he is planned to have elective hernia repair," for a chronic, asymptomatic, incarcerated, fat-containing, left inguinal hernia.

The patient's vitals were as follows: Temperature 36.5, pulse 82, blood pressure 109/67, respirations 18, oxygenation 99%, pain 0/10. Physical examination demonstrated a left inguinal hernia.

The patient was admitted at an acute inpatient level-of-care for elective inguinal hernia repair. He was deemed, "UNSAFE FOR DISCHARGE OR UNABLE TO BE COMPLIANT WITH OUTPATIENT THERAPY. Unable to be Complaint with Outpatient Medical Treatment as a Result of: Underlying psychiatric issue, Poor social supports and low health literacy." Indeed, previously, "Per psychiatry patient received Invega sustenna injection 11/12 IM [intramuscular], long term and will not need repeat injection." Despite the fact that the patient wanted to undergo repair, he eloped.

No, the Inpatient admission was not medically necessary.

The patient did not require admission for either his hernia or his mental illness.

The patient was stable with normal vital signs and no evidence of physiologic derangements. The patient did not report any symptoms or complications associated with his hernia -- no pain, no gangrene, no obstruction.

The patient did not report any acute mental health changes -- "no emergency complaints." The patient received long-acting psychiatric medications and did not need re-treatment until after the dates-in-question -- "Per psychiatry patient received Invega sustenna injection 11/12 IM [intramuscular], long term and will not need repeat injection."

Therefore, despite a history of hallucinations/delusions/psychoses and pharmacologic non-compliance, there was no need for admission at an acute inpatient level-of-care. In the setting of clinical stability, the patient could have been treated at a lower level-of-care.

Despite a history of hallucinations/delusions/psychoses and pharmacologic non-compliance, there was no need for admission at an acute inpatient level-of-care. In the setting of clinical stability, the patient could have been treated at a lower level-of-care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uncomplicated sickle cell pain crisis.
Treatment: Inpatient admission.

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

This is a female patient with sickle cell anemia who presented to the Emergency Room (ER) with generalized body pain stated to be consistent with her usual pain crisis.  Her physical exam was unremarkable.  Her oxygen saturation was 95%, heart rate 56 and blood pressure (BP) 103/56.  A chest x-ray (CXR) was negative.  She was admitted to the hospital for uncomplicated pain crisis.  She was given hydration and pain medications and discharged 2 days later.

For an individual with an uncomplicated sickle cell pain crisis with normal vital signs, no hypoxia, negative chest x-ray, and stable hemoglobin with no evidence of infection, an acute level of care is not warranted.  These patients can be safely managed in alternative care settings such as observational care.  

Per Simon E. et al. (2016), "SCD [sickle cell disease] patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition."

Per Cline, D. M., Silva, S., Freiermuth, C. E., Thornton, V., & Tanabe, P. (2018), "Use of alternative venues to manage uncomplicated vaso-occlusive crisis (VOC), such as a day hospital (DH) or ED [Emergency Department] observation unit, for patients with sickle cell anemia, may significantly reduce admission rates, which may subsequently reduce 30-day readmission rates."

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

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

The carrier's denial of coverage for the inpatient admission is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD) and asthma.
Treatment: Airway Clearance Therapy, High Frequency Chest wall Oscillating (HFCWO) Device.

The insurer denied coverage for Airway Clearance Therapy, High Frequency Chest wall Oscillating (HFCWO) Device.  The denial is upheld. 

This is a male patient with a history of chronic obstructive pulmonary disease (COPD) and asthma. The patient has been treated with multiple medications for both. The patient had been relatively asymptomatic. The patient presented to a physician with complaint of some shortness of breath (SOB), cough with sputum production and wheezing. The patient reported history of COPD exacerbations. The patient had tried manual physiotherapy to improve mobilization of secretions and sputum production but that reportedly had not helped. The patient was prescribed a Vest High Frequency Chest wall Oscillating (HFCWO) device. Multiple office visits document that patient is non-compliant with his inhalers. The patient is also receiving biologics for asthma. The patient's pulmonary function test (PFT) results reveal mild COPD, with forced vital capacity (FVC) of 2.6, forced expiratory volume (FEV1) of 1.4; ratio FEV1/FVC of 55%. Imaging studies revealed mild hyperinflation on chest X-ray (CXR). The patient's chest tomography (CT) scan showed mild emphysema and 2 millimeter (mm) lung nodule. There is no documentation of any infection or inspissated mucus. A recent note documents that the patient is asymptomatic. The review of system (ROS) does not reveal any increased sputum production or cough. The patient was afebrile and hemodynamically (HD) stable with oxygen saturation of 97% on room air.

Based on the review of the medical record, high frequency chest compression (HFCWO) is not considered medically necessary for this patient.  The main indication for the use of HFCWO is in patients with cystic fibrosis and/or chronic bronchiectasis. There is no documentation of these conditions or retention of secretions for this patient. The patient's symptoms are mild. Other therapies, such as manual chest physical therapy (PT) and flutter valve are effective to mobilize secretions in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This patient did not have any significant mucous production or retention as per review of system (ROS).

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

The medical necessity for Airway Clearance Therapy, High Frequency Chest wall Oscillating (HFCWO) Device is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Increase Personal Care Aide Services from 5 Days per Week Live-in to 7 Days per Week Live-In. 

The insurer denied the Increase Personal Care Aide Services from 5 Days per Week Live-in to 7 Days per Week Live-In. 

The denial is overturned. 

The patient is a female with a history of cognitive impairment and gait ataxia secondary to dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in personal care aide services from 5 Days per Week Live-in to 7 Days per Week Live-In to offer increased ADLs (activities of daily living) support. 

Yes, the proposed treatment of an increase in personal care aide services from 5 Days per Week Live-in to 7 Days per Week Live-In is deemed medically necessary. 

Recent documentation received from the patient's medical provider indicates that due to progressively worsening cognitive impairment and gait ataxia, the patient has become progressively more confused with significant decline in her ability to complete ADLs (activities of daily living) and requires extensive/full time assistance for all forms of ambulation. Hence, the currently approved plan of 5 Days per Week Live-in Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 7 Days per Week Live-In Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis, Skin disorders
Treatment: Inpatient hospital stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a male with a past medical history significant for asthma, benign prostatic hyperplasia (BPH), paroxysmal atrial fibrillation, morbid obesity, lymphedema, and recurrent episodes of cellulitis who presented to the hospital for evaluation of fever, right leg pain, and generally feeling unwell. The symptoms started on the day of admission. The patient denied chest pain, shortness of breath, abdominal pain, and vomiting. The patient stated that his leg pain was similar to the previous episodes of cellulitis. It was reported that he was discharged from another hospital approximately 1 week before the day of the presentation. The patient stated that he was treated for a urinary tract infection and at the time of admission was taking Macrobid and Doxycycline.

The inpatient hospital admission was medically necessary as the lower extremity cellulitis was associated with sepsis syndrome.
This coincides with Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 24th Edition criteria for Cellulitis. Based on the criteria, the admission at the acute inpatient level of care was justified by the clinical presentation, which was judged to require the intensity of patient monitoring that could not be provided at other than the inpatient level of care. The level of monitoring was justified by the diagnosis of severe sepsis based on the systemic inflammatory response syndrome (SIRS) criteria.
Appeal type: Medical necessity
Decision: Upheld

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

The patient has a past medical history (PMH) of bronchial asthma and was admitted with complaints of (c/o) a two-week history of right toe pain after cutting it in the shower. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), right large toe with erythema and tenderness to palpation (TTP). Lab work was notable for a white blood cell count (WBC) of 11.4. A right toe radiograph showed no acute changes. The patient was previously diagnosed with cellulitis and orthopedics recommended a hard-soled shoe, conservative management, and oral cephalaxin with anti-inflammatories as an outpatient. The patient returned with worsening pain, received an incision and drainage (I&D) and began intravenous (IV) antibiotics for right foot cellulitis. Due to continued pain, a second I&D was performed. The culture showed methicillin-susceptible staphylococcus aureus (MSSA). Orthopedics did not feel a septic joint was likely. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The inpatient hospital stay was not medically necessary. The patient presented to the ED(Emergency department) with c/o two-week history of right toe pain after cutting it in the shower. She was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with clinical monitoring, IV antibiotics, and I&D, and this could have been safely provided at a lower level of care. to allows frequent reevaluation to assess response to therapy. Overall, this patient could have been safely treated at an observation level of care.
Regarding the provided InterQual criteria, the patient was not immunocompromised, did not have an infection over prosthesis or orbital cellulitis, no diabetic foot ulcer, or herpes zoster.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: C7/T5 spinal cord injury with T3/T4 burst fracture with multiple injuries.
Treatment: Non-Emergency Air and Ground Ambulance Transportation.

The insurer denied the Non-Emergency Air and Ground Ambulance Transportation.  The denial is overturned.

The patient is a male with history of a motorcycle accident.  He sustained a C7/T5 spinal cord injury with T3/T4 burst fracture with multiple injuries and was admitted to one facility where he had multiple surgeries.

The patient's medical management team decided to transfer him to an acute inpatient rehabilitation facility in another state for continued medical care and intensive, multi-disciplinary spinal cord injury medicine neurorehabilitation, due to a need for specialized care at a facility of a higher standard than that available in the original state that will also enable him to be close to his family and friends.

Yes, the requested air ambulance service was medically necessary.

The requested air ambulance was in accordance with generally accepted standards of medical practice for transportation of that type of patient with such type of condition over such a long distance of transportation.  

Part of the rehabilitation process requires members of the family to be involved towards transition to being discharged home and continued aftercare that will involve the family.  Transfer was clinically appropriate and it was not mainly for the convenience of the physician or any other health care provider.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient as the request for transfer was from an acute care hospital to a rehabilitation hospital where family support will be needed as part of the rehabilitation process.

An air transportation is the appropriate method for a significant distance for which any other form of transportation would have been inappropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Double Vision
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented to the emergency ward with two transient episodes of diplopia. At presentation, he had a normal neurological examination and neuro-imaging. He was admitted for possible TIA (transient ischemic attack).

No, the inpatient admission was not medically necessary.

The patient presented with possible TIA (transient ischemic attack). His vital signs, neurological examination and neuro-imaging were all normal. Current risk stratification guidelines for TIA (transient ischemic attack) suggest that his risk for subsequent stroke, based on presenting symptoms, examination findings, past history and neuro-imaging results, was low. Therefore, acute inpatient was not medically necessary. The diagnostic studies, monitoring, neurological consultation and treatment could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease, anemia and right hip arthritis.
Treatment: Inpatient admission.

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

This is a female with a past medical history of Crohn's Disease, anemia and right hip arthritis. She was admitted to hospital for an elective right total hip arthroplasty. Her post surgical course was non complicated.

No, the proposed inpatient admission was not medically necessary.

The medical records demonstrate a non-complicated post surgical course. The patient did not have a medical condition to warrant additional service. Her operation was without problem. The blood loss was as expected for a hip replacement. Her post surgical hematocrit were as expected taking into consideration her iron deficiency anemia. There were no problems with her wound. There was no evidence of infection. She was able to tolerate oral pain medications. Progress was made with physical therapy (PT) services. She did not require additional treatment nor imaging (i.e., there was no evidence of bleeding, infection or pain to require ongoing hospitalization). 

The Milliman Care Guidelines (MCG) criteria for extended stay were not met. 

There was no reason services could not have been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis status post right hip replacement.
Treatment: Inpatient admission.

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

This is a male with osteoarthritis to his right hip. He underwent a right total hip
replacement. His post-surgical course was non-complicated. He had some
problems with physical therapy (PT) but was discharged to home with occupational
therapy (OT) services and home care.

No, the proposed inpatient admission was not medically necessary.

The medical record demonstrated a non-complicated surgery and recovery. The
patient's vital signs were stable. There were no post-surgical complications to
require additional testing nor consultation. The patient did not require treatment for
underlying medical issues. There was no evidence of bleeding, infection, fever or
pain to require continued hospitalization. The criteria utilized were applicable and
consistent with current practice. There were no extenuating circumstances to
substantiate the admission and length of stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied braces.  The denial is upheld.

The patient is a female with a Class I occlusion with 5 millimeter (mm) overbite and 3 millimeter (mm) overjet. She has mild maxillary crowding and moderate mandibular crowding. She is treatment planned for orthodontics to correct her malocclusion which was denied by the health plan based on lack of medical necessity. The subject under review is the medical necessity for the braces.

The health plan's determination is upheld.

Braces are not medically necessary for this patient. The patient has some crowding. Her overbite is appropriate and there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows she does not have a traumatic deep bite. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. Her handicapping labio-lingual deviation (HLD) score is 13 (5 overbite, 3 overjet, 5 mandibular crowding). This is below the threshold for medical necessity.
While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. (2) If her teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.