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

Diagnosis: Right groin abscess
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned in part.


The patient presented to the emergency department (ED) with right groin swelling and pain of 2-days duration. Her past medical history is notable for coronary artery disease, schizophrenia, hypertension, and diabetes. At the time of presentation, there was swelling of the right groin. She was without a fever though her heart rate was elevated (113 beats/minute). Imaging (a computed tomography (CT) scan) did identify an abscess of the right groin. She was admitted to the hospital.
The white blood cell count (WBC) count was elevated at 20.3 thousand (K). Surgical consultation was obtained. She was treated with intravenous (IV) antibiotics and surgical drainage of the abscess. Her temperature was normal, the heart rate was 102 beats/minute and her other vital signs were normal. The WBC was down to 15 K. Serum electrolytes identified a slightly low corrected sodium value. The glucose level was elevated at 371. She was treated for hyponatremia and diabetes. She received IV antibiotics. The pain was controlled and she was started on a diet.
The next day, the WBC was down to 11.5 K and the sodium value was 130. The glucose was normalized to 126. A psychiatric consultation was requested for her diagnosis of schizophrenia. She was receiving IV antibiotics (Vancomycin and Cefoxitin). The WBC count was normal at 9.2 K. The sodium was up to 132 and glucose was 219. Pain was controlled with oral medications. The infectious disease consultant recommended oral antibiotics. The treatment plan included discharge to a skilled nursing facility for wound care. The patient received daily wound care and was considered to be stable for discharge from the hospital to her home. She was provided ongoing oral antibiotics and instructions for wound care.
At issue is the medical necessity of an inpatient stay.

Yes, the services were medically necessary in part. The records do support that there were acute clinical issues that mandated an inpatient stay for 5 days. The patient presented and was admitted to the hospital  with a right groin abscess. 
She required urgent surgical intervention which was performed, provision of IV antibiotics, post-surgical wound care, coordination of care with infectious disease, surgery and psychiatry, and treatment of hyponatremia and diabetes. However, as of the sixth day, the patient was clinically stable with normalization of the WBC count and the antibiotics were converted to oral delivery.  Her clinical needs could have appropriately been managed at a lower level of care as of that time.

The care provided was most appropriately rendered in the inpatient setting for the first 5 days. However, the care provided after that could have reasonably been rendered at a lower level of care and did not require continued inpatient care. The patient was clinically stable with a normalized WBC count, normal vital signs and she was converted to oral antibiotics based on the recommendations of the infectious disease service.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male child with medical history significant for prematurity born at 36 weeks gestation, choking with feeds, dysphagia, and concern for laryngeal cleft who was admitted post-operatively following endoscopic repair with rigid bronchoscopy. Following sedation with Precedex, he had two episodes of bronchospasm treated with albuterol and Propofol, he also received a normal saline bolus and a dose of dexamethasone. He subsequently developed stridor, which was treated with racemic epinephrine. He was admitted for post-operative respiratory monitoring. 

The requested acute inpatient admission was not medically necessary for this young male patient admitted following surgical repair of laryngeal cleft complicated by post-operative stridor. He could have been safely and appropriately managed at lower level of care.
Post-extubation stridor is a sign of edema and airway obstruction, more pronounced in children than adults due to differences in airway anatomy. It is a potentially life-threatening complication associated with prolonged intubation, longer hospital stay, and higher mortality rate. Intravenous corticosteroid administration is generally the treatment of choice due to the anti-inflammatory effects and reduction in edema. Racemic epinephrine may also be used for symptomatic management. Patients requiring this level of intervention merit monitoring in a monitored setting.
This young male child was taken to the operating room for management of a presumed laryngeal cleft. He did well in surgery, albeit with two episodes of bronchospasm and post-operative stridor. He was treated with racemic epinephrine and dexamethasone and admitted to the Pediatric Intensive Care Unit (PICU) for further management. While it was medically necessary and appropriate to monitor this child in the hospital, he was overall hemodynamically stable with no evidence of impending respiratory failure. He responded well to steroid administration. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a female with no significant past medical history remarkable who presented for upper and lower extremity weakness/numbness, eye pain and short-term memory lapse. Review of system was negative for additional clinical symptoms.
The patient was afebrile (Temperature of 97.7). She was described as alert and no acute distress. Her blood pressure was 108/70, pulse rate of 78, respiratory rate of 16, and oxygen saturation of 100% (percent) on room air. Physical examination was unremarkable for positive clinical findings. The neurologic examination was reported as normal.

The inpatient hospital admission was not medically necessary. The inpatient admission was not medically necessary. The care could have been safely rendered at a lower level for IV (intravenous) hydration and syncope workup.
The patient was admitted for reports of multiple symptoms that were thought to be related to the patient's underlying psychiatric disorder. The patient did not have objective neurologic findings or positive findings on imaging. The patient was evaluated by a psychiatrist and did not warrant inpatient psychiatric admission. Observation would have been most appropriate for evaluation and psychiatric consultation.
Exacerbations of Multiple Sclerosis (MS) have been typically defined as episodes of focal neurological disturbance lasting more than 24 hours, without an alternate explanation, and with a preceding period of clinical stability lasting at least 30 days. Relapses in multiple sclerosis have been attributed to the occurrence of new white matter lesions. Treatment usually entails high dose intravenous steroids. In this case, the patient presented with no clear symptoms of demyelinating disease. The patient did not have any visual symptoms that represented optic neuritis or other signs of MS.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic inflammatory disease/muscle wasting.
Treatment: Physical therapy, 02 visits.

The insurer denied coverage for physical therapy, 02 visits.
The denial is overturned.

This is a female with past medical history of pelvic inflammatory disease/muscle wasting. The patient has experienced urinary frequency, incomplete bladder. Also, complaint of pelvic and lower back pain. Patient was advised to have physical therapy and did receive physical therapy (PT) services. Per PT progress note, the patient still had ongoing pain plus discomfort, but has steady progression with PT. Treatment procedures include therapeutic exercises/activities, Neuromuscular rehabilitation, manual therapy. 

The appeal by the patient is noted and read in detail. The patient note references decreasing tenderness lumbar spine, lower abdomen, and improving tone of the pelvic floor muscles. Material also reference improving ability to control urge to urinate, patient able to perform bending and lifting light weight without aggravation patient still has "weak pelvic floor muscles." However, the patient goals at this visit reference 2 visits per week for 6 more weeks for 12 more visits. The doctor note describes the patient as likely benefiting from pelvic floor therapy - specifically down training for this condition. This reviewer agrees with the need for additional PT visits and the additional visits are considered medically necessary:

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

The patient visits requested are considered medically necessary for this patient.

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

The insurer's denial of coverage for physical therapy, 02 visits requested is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer

Treatment imaging service (CPT code 74177)

The insurer denied coverage for imaging service (CPT code 74177)

The denial is upheld

The patient is a female with was diagnosed with T2N0 (tumor size >2 to 4.9 cm) breast cancer. The patient completed six cycles of TCHP (Taxotere, carboplatin, Herceptin, Perjeta) and was then started on anastrozole and continued on zoladex. Perjeta was added to adjuvant Herceptin treatment.  She had a bilateral mastectomy with reconstruction, there was no residual cancer at that time.  She completed Herceptin and pertuzumab. Pulmonary nodes were noted as stable per follow-up. The service under review is a computed tomography (CT) scan done for surveillance.

The plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The patient has had the pulmonary nodules for some time, and they remained stable. The patient has not had any new complaints and is asymptomatic.      

The imaging service (CPT code 74177) performed is not considered medically necessary for this patient. There is no evidence to support surveillance CT scans in women with breast cancer.  This is specifically not recommended by the NCCN (National Comprehensive Cancer Network) to have surveillance CT performed. 

Per Moschetti et al., (2016), "This updated review of RCTs (randomized controlled trial) conducted almost years ago suggests that follow-up programs based on regular physical examinations and yearly mammography alone are as effective as more intensive approaches based on regular performance of laboratory and instrumental tests in terms of timeliness of recurrence detection, overall survival and quality of life. In two RCTs, follow-up care performed by trained and not trained general practitioners working in an organized practice setting had comparable effectiveness to that delivered by hospital-based specialists in terms of overall survival, recurrence detection, and quality of life." 

Early diagnosis of metastatic disease, based on imaging alone and prior to the onset of clinical signs or symptoms, may result in an earlier intervention, with associated toxicities, but does not improve survival. Although a small percentage of patients with limited metastatic disease (eg, isolated pulmonary or liver metastases) may be treated with a multimodality approach, whether such patients are best identified by intensive post-treatment surveillance is unknown. Furthermore, laboratory and imaging tests used for surveillance have significant false-positive and false-negative rates and increased costs.

There is no role for imaging to evaluate long-term stable pulmonary nodules.

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

The insurer's denial of coverage for the imaging service (CPT code 74177) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: AVF (arteriovenous fistula) creation.
Treatment: Inpatient admission.

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

The patient was admitted for elective surgery for AVF (arteriovenous fistula) creation, she was found to have hyperkalemia and was treated with Lokelma. She started to feel a little bit dizzy and was kept after procedure for monitoring and discharged.

Based on the patient's presenting signs/symptoms and the predictability of something adverse that will occur to the patient based on these presenting signs/symptoms, her level of acuity did not meet any guideline requirement for inpatient hospitalization.  When taking into account the patient's exam, imaging, and lab findings as well as the lack of need for diagnostic testing beyond what was done in the ER (emergency room) and the availability of any additional diagnostic testing as an outpatient, there was no clinical criteria for inpatient level of care.  Overall, the patient's condition could have been managed safely on an observation basis. Nothing was done for the patient during her inpatient level of care that could not have been or had not already been managed on an observation level of care. Based on all these reasons, she had no requirements for inpatient level of care.

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

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


The patient has a past medical history (PMH) of acute calcaneal fracture and was admitted with complaints of (c/o) acute left heel pain after a mechanical fall. The patient stated that she was instructed by podiatry to come to the emergency department (ED) to be admitted for an open reduction internal fixation (ORIF) left calcaneus. Her vital signs were unremarkable. Of note, the ED documentation notes a pain level of zero. The physical exam was notable for left rear foot tenderness. Lab work was notable for a sodium of 131. A left calcaneal radiograph showed a comminuted closed calcaneal fracture of left foot, a left foot computed tomography (CT) showed a comminuted impacted intra-articular fracture of anterior and mid-body. The patient was diagnosed with a closed left calcaneal fracture and treated with a left calcaneal ORIF. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED after a left calcaneal fracture and being told to present for admission for procedure several days after the initial injury. The patient was stable, had no severe pain, and received a diagnostic imaging workup with radiographs that showed a closed left calcaneal fracture. Podiatry admitted the patient and the patient underwent a non-emergent left calcaneal ORIF two days after admission. Of note, the patient was noted to have a Revised Cardiac Risk Index (RCRI) risk class of I. Overall, this low-risk patient received a non-major surgical procedure on a non-emergent basis, and these interventions could have been safely and appropriately provided at a lower level of care.

Regarding the provided criteria, the patient did not have vertebral fracture requiring observation for instability, compartment syndrome, major injury requiring inpatient stabilization, major injury requiring inpatient treatment after emergency care, limb-threatening injury, or severe pain requiring inpatient management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colon cancer, arthritis, asthma, and short term memory loss. 
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) services to 10 hours per day, 7 days per week, for a total of 70 hours per week. 

The insurer denied the increase in CDPAP services to 10 hours per day, 7 days per week, for a total of 70 hours per week. 
The denial is overturned. 

The patient is a female. Her conditions include colon cancer, arthritis, asthma, and short term memory loss. Denial of increase consumer directed personal assistance program (CDPAP) services 10 hours per day, 7 days per week, for a total of 70 hours per week is being appealed. The plan approved CDPAP services 4.5 hours per day, 7 days per week, for a total of 31.5 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparations, managing finances and medication, stairs, shopping, and bathing; extensive assistance with transportation, dressing, walking, toilet transfer, locomotion, and bed mobility; limited assistance with toilet use; supervision with eating; and independent with personal hygiene. UAS evaluation performed compared to previous evaluation shows a decline functional status with upper body dressing, bathing, walking, locomotion, eating, and bed mobility. She has occasional bowel and bladder incontinence. A letter on behalf of the patient's provider notes the patient needs assistance with ADLs (activities of daily living). 

Yes, the increase in CDPAP services to 10 hours per day, 7 days per week, for a total of 70 hours per week is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. 

This patient has multiple chronic conditions. UAS evaluation completed shows the patient requires assistance with all ADLs/IADLs (instrumental activities of daily living) except eating and personal hygiene. UAS evaluation performed compared to previous evaluation shows a decline functional status with upper body dressing, bathing, walking, locomotion, eating, and bed mobility. She has occasional bowel and bladder incontinence. This patient has limited physical functioning that has deteriorated over two months. The level of impairment and need for assistance with ADLs and personal care cannot be met with the current CDPAP 31.5 hours per week. The proposed increase in CDPAP to 70 hours per week is medically necessary to meet this patient's need for assistance with ADLs and personal care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Ptosis. 
Treatment: Mastoplexy (breast lift surgical procedure). 

The insurer denied coverage for mastoplexy (breast lift surgical procedure). 

The denial is upheld. 

The requested procedure is not medically necessary. The records do not include photos, a note from a plastic surgeon documenting a plan for breast surgery, or an assessment of the planned weight of the reduction. Mastopexy is a cosmetic procedure. According to a article by DiSuma et al: "Mastopexy is one of the most performed cosmetic surgery procedures in the U.S [United States]."  A study by Watfa et al also states: "Mastopexy is one of the most performed cosmetic surgery procedures in the United States. "Mastopexy is a cosmetic procedure for all indications and is cosmetic for this indication According to Chapter 58, Grabb and Smiths Plastic Surgery, "Mastopexy is a procedure designed to elevate breast tissue and the nipple-areola complex to correct breast ptosis. Mastopexy procedures are derived from breast-reduction procedures except that only skin is removed with little or no parenchymal resection. Breast reduction surgery is often performed to relieve neck, back, shoulder, and arm pain. The patient receives significant medical and quality-of-life benefits. Although the appearance of the breast is a factor, the medical benefits are often the primary concern of the patient. Mastopexy is almost always a cosmetic procedure. Consequently, the trade-offs (i.e., scars) are less well tolerated by the mastopexy patient than by the breast-reduction patient."  There are no peer-reviewed studies that show that mastopexy is an effective treatment for musculoskeletal pain or is a superior treatment to dermatology management for rashes. According to the American Society of Plastic Surgeons, "Most health insurance plans will not cover breast lift surgery, related complications or another surgery to revise the appearance of your breasts."  Mastopexy is a cosmetic procedure and is not medically necessary. 

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

The insurer's denial of coverage for mastoplexy (breast lift surgical procedure) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stenosis of the right coronary artery (RCA) and the left anterior descending (LAD)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient has a history of coronary artery disease, diabetes, peripheral polyneuropathy, and hyperlipidemia. He complained of chest pain. Echocardiogram showed 30-35% (percent) ejection fraction. He underwent diagnostic cardiac catheterization and was found to have a high-grade stenosis of the right coronary artery (RCA) and the left anterior descending (LAD) artery. He had a drug eluting stent implanted to the RCA. The patient presented to the hospital for an elective staged cardiac catheterization with percutaneous coronary intervention (PCI) to the LAD artery. A drug eluting stent to the LAD was implanted successfully. The patient was admitted and observed and monitored uneventfully overnight and discharged.

The patient had an elective coronary intervention. It was reasonable to observe the patient for several hours after intervention to assure clinical stability and no adverse cardiac outcomes or bleeding. A full admission was not necessary.

A short period of observation to assure no acute complications such as bleeding was appropriate, but that could have been performed on observation status.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.