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

Diagnosis: Acute myeloid leukemia (AML). 
Treatment: Chemotherapy. 
The insurer denied Xospata. 
The denial is upheld. 

The patient is a male with FLT3 positive acute myeloid leukemia (AML) who underwent stem cell transplant. He has received chemotherapy in the past. Xospata was given to the patient for maintenance treatment.
At issue is the medial necessity of Xospata 40 milligrams (mg) tablet (tab).

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Xospata 40 mg tab is not medically necessary for this patient.
According to National Comprehensive Cancer Network (NCCN) guidelines, the recommended agent to treat AML after allogeneic transplant for maintenance is Sorafenib. Xospata is indicated for relapsed or refractory AML in adult patients with a FLT 3 mutation. There is no documentation of this patient being relapsed or refractory.
Therefore, the requested service/treatment of Xospata 40 mg tab is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Osteoarthritis. 
Treatment: Home Health Care. 

The health plan denied the requested increase in personal care assistant services. The health plan's determination is upheld. 

The patient is a female with a past medical history of stroke, diabetes, chronic kidney disease, and auditory hallucinations. 

The patient was assigned services based on an assessment, assessing the patient to be minimally impaired with memory problems, moderate hearing difficulty and moderate vision difficulties. The patient was assessed to be totally dependent with the task of meal preparation and housework, and extensive assistance with medications and shopping. The patient was assessed at extensive assistance with tasks of bathing, personal hygiene, dressing upper body and dressing lower body, limited assistance with walking toilet use and transfers, limited assistance with bed mobility and limited assistance with eating. The patient is frequently bladder incontinent and occasionally bowel incontinent. 
The patient's primary care provider wrote a letter of medical necessity. The physician noted that the patient has multiple medical problems and is functionally and cognitively impaired and requires assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The physician also stated that patient suffers hallucinations at night and is reassured with companionship. 

The patient was evaluated by her primary care physician, who noted that the patient continues to suffer from visual and auditory hallucinations and a declined psychological evaluation. Hallucinations are worse at night. 

This review is regarding the medical necessity for an increase in Personal Care Aide (PCA) services to 24 hours per week, live in Monday-Sunday. The patient is currently approved for 56 hours weekly. 

The health plan's determination is upheld, in whole. 

The requested service is not medically necessary. 

The patient requires assistance for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Based on the Uniform Assessment System (UAS), she was assessed to require 31 hours of assistance. The patient has not had any recent hospital admissions or new documented change in functional status to require an increase in hours. The patient needs limited assistance with toileting and bed mobility. It is documented that the patient does suffer from hallucinations, however, given that there is no documented need for tasks to be done during nocturnal hours, additional hours are not necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ankle fracture.
Treatment: inpatient stay.
The insurer denied Continued Inpatient Stay at Subacute Facility. 
The health plan's determination is upheld. 

The patient is a female with history of ankle fracture, paranoid schizophrenia, chronic obstructive pulmonary disease, hypertension, and hypothyroidism who returned to subacute rehabilitation after being discharged from the hospital. The patient was alert and oriented on arrival. Medication reconciliation was performed and maintenance medications provided. Multiple consultations, including psychiatry, were obtained. Multiple behavioral issues were documented, but none to the point where it was felt the patient needed to return to the hospital. Social services began discharge planning with the patient. The patient was noted to be able to independently transfer to and from the wheelchair, propel the wheelchair, and perform safety tasks such as locking wheelchair brakes. Orthopedic surgery recommended the patient could be weight bearing as tolerated on the left.

Based on the clinical documentation provided, evidence based literature and standards of care, continued inpatient stay at subacute facility was not medically necessary.
The patient was admitted to the subacute rehabilitation after being hospitalized for an ankle fracture. The patient was of non-weightbearing status and proceeded with rehabilitation via therapy services. Behavioral issues were documented and addressed by the attending physician and psychiatrist. There was no documentation that the patient required inpatient psychiatric care and thus the patient was not returned to the hospital. The patient progressed and was documented as independent with the wheelchair. The patient followed up with the orthopedic surgeon who removed activity restrictions and recommended weight bearing as tolerated. The patient was deemed medically stable and actually left the facility, independently, on a pass. The discharge plan had been communicated with the patient for at least a month. Appointments had been planned or scheduled. Medical equipment had been arranged and referrals were made for assistance or support. The attending physician documented the patient was medically stable. There was no documentation provided that supported continued inpatient stay at the subacute rehabilitation for the days in question.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

The patient is a pregnant female who presented to the emergency room with persistent vomiting for two days. Her electrolytes were normal. Urinalysis showed trace ketones. The patient was admitted and received intravenous (IV) fluids and vitamins, Zofran 4 milligrams (milligrams) IV every 8 hours, Prochlorperazine IV every 8 hours and Vitamin B 6 IV every 8 hours. she was discharged after tolerating a oral diet.

As per ACOG (American College of Obstetricians and Gynecologists), there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum. When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended. After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

According to UpToDate: Women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance with the initial interventions described above should be admitted to the hospital for intravenous fluids and medications. Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital. The decision to admit versus discharge to home needs to be individualized based on the patient's severity of disease, resources, ability to comply with the management plan, and ability to obtain and have access to outpatient resources.

This patient did not have hyperemesis gravidarum. There is no report of weight loss, her electrolytes were normal. She had trace ketones only. She had some vomiting of pregnancy and needed hydration. IV hydration does not require hospital admission.

The health care plan acted 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 insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures. 
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is overturned. 

This case involves a male with a history of seizure disorder who presented to the emergency room complaining of 3 witnessed seizures. Records indicated the patient fell and hit his head after forgetting to take his Keppra. He was given a loading dose of Keppra in the emergency room and was found to have a scalp hematoma. The attending physician subsequently admitted the patient for care in which he underwent an electrocardiography with Q waves in lateral leads. Diagnostic imaging revealed a large right parietal vertex hematoma. Records stated the patient was admitted due to breakthrough seizures with plans to consult neurology and administer pain control and obtain labs. The patient received a notice of adverse determination regarding the inpatient stay. It was stated that the patient could have been placed on observation care for monitoring and that he did not require inpatient level of treatment. This is due to a lack of hemodynamic, pulmonary, metabolic, or neurological reasons. This review pertains to the denial of coverage for the inpatient admission. 

The Milliman care guidelines (MCG) indicate that a goal length of stay for a patient who is suffering from seizures is 2 days. Clinical indications for admission to inpatient care include hemodynamic instability, status epilepticus, brain disorder to include tumor, edema, trauma, hydrocephalus, encephalitis, or meningitis that requires monitoring or intervention available only at inpatient level of care. According to MCG, inpatient admission is indicated for seizure for patients with hemodynamic instability, status epilepticus, cardiac arrhythmias, severe or persistent altered mental status, new neurological deficits, recurrent seizure (during ED or observation care), and when outpatient anti-seizure regimen cannot be established. Additional indications for admission include that an outpatient epileptic regimen cannot be established, if the patient has cerebral bleeding, hydrocephalus, or needs vasospasm monitoring and when there is increased intracranial pressure or cerebral edema requiring monitoring. The information provided for the review noted that the patient reported that he had forgotten to take his Keppra and suffered multiple seizures. He endorsed falling and hitting his head and was found to have a scalp hematoma. Records also stated that the patient had a seizure 2 days earlier and consisted of tongue biting with a first seizure with reports that the patient was taking his Keppra intermittently. Given the patient's recurrent seizures and subsequent head injury, it was reasonable to place him on an inpatient level of care for treatment purposes. As such, the inpatient admission was considered medically necessary for this patient. The prior determination is overturned. 

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

Diagnosis: Plaque psoriasis.
Treatment: Stelara 90 mg/ml.
The insurer denied the Stelara 90 mg/ml.
The determination is upheld.

The patient has plaque psoriasis. He has tried and failed clobetasol. He has also failed Otezla, ketoconazole shampoo and hydrocortisone. He has a negative Quantiferon tuberculosis (TB) test. The medication under review for medical necessity is Stelara 90 milligrams per milliliter (mg/ml).

The requested health service/treatment of Stelara 90 mg/ml is not medically necessary for this patient.
The standard of care is to treat a patient with the Food and Drug Administration (FDA)-approved dosing, which in this case would be Stelara 45 milligrams (mg) rather than Stelara 90 mg.  According to the "national physician specialty society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, Stelara is an effective treatment for the management of psoriasis (1-3). Langley et al. writes "Treatment with ustekinumab for up to 5 years was safe and effective" (3). After review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Stelara 90 mg as there is no documentation provided the patient has tried Stelara 45 mg dosage for 3 months and had an adverse effect or proof that this dose did not work for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized Weakness and Belly Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with diabetes, hypertension, and hyperlipidemia who presented with chest pain and epigastric pain. She had low appetite for 5 days and had not been taking insulin.

The patient's blood pressure was 101/70, heart rate 123, respiratory rate 18, temperature 98.3, and O2 (oxygen) 99% (percent). The patient's Glucose was 522 mg/dL (milligrams per deciliter), sodium 116, bicarbonate 17. Chest x-ray showed potential pneumonia and COPD (chronic obstructive pulmonary disease).  She was treated with azithromycin. Radiology read was mild COPD (chronic obstructive pulmonary disease) changes, no pneumonia. CT (computed tomography) of abdomen was concerning for pancreatitis.  The patient was given 2 mg (milligrams) of Dilaudid.

The inpatient stay for dates of service is under review. The prior request was denied coverage by the health plan, as the request does not meet InterQual criteria for diabetic ketoacidosis or pancreatitis. This denial is being appealed.

No, the Inpatient admission was not medically necessary.
The InterQual criteria for diabetic ketoacidosis requires all of the following: blood glucose greater than 250, pH (potential hydrogen) 7.25-7.30, and elevated beta-hydroxybutyrate or ketones. The patient's glucose was elevated at 522 and positive serum ketones, but her pH was normal at 7.33. Therefore, the inpatient stay did not meet InterQual criteria for diabetic ketoacidosis.

The InterQual criteria for pancreatitis requires two or more: abdominal pain consistent with pancreatitis, amylase/lipase three or more times over the upper limits of normal, or pancreatitis confirmed by imaging and one of the following: mental status change, pleural effusion or pneumonia confirmed by imaging or hematocrit of 44% or more after aggressive fluid resuscitation and intervention of two or more doses of pain medication in the emergency room without resolution of pain and on continuous pain medication or pain medication four or more doses in 24 hours and on intravenous fluids. The patient had abdominal pain and pancreatitis confirmed by imaging. The documentation does not support mental status change, pleural effusion or pneumonia confirmed by imaging or hematocrit of 44% or more after aggressive fluid resuscitation and intervention of two or more doses of pain medication in the emergency room without resolution of pain and on continuous pain medication or pain medication four or more doses in 24 hours and on intravenous fluids. The final chest x-ray read was "Mild COPD [chronic obstructive pulmonary disease] changes noted. No pneumonia."

Therefore, given the above, the inpatient stay dates of service was not medically necessary.

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

The requested inpatient stay was not medically necessary and was appropriately denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legally blind
Treatment: Increase Home Care/Personal Care HHC Level 2 Per 15 minutes to 42 Hours Per Week
The insurer denied the Increase Home Care/Personal Care HHC Level 2 Per 15 minutes to 42 Hours Per Week
The denial is overturned.

The patient is a female. She is reportedly legally blind. The request is for Increase Home Care/Personal Care Level 2 Per 15 minutes to 42 Hours Per Week.

Yes, the requested increase in services to 42 hours/week is medically necessary.
The patient is blind and needs constant care. She is dependent on her caregiver for all her ADLs (activities of daily living). 30 hours/week is not enough, and she needs more hours to help with ADLs (activities of daily living), including transfers, going to bathroom, cooking, cleaning showering, meals, etc.

The requested increase to 42 hours/week is appropriate and medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient needs more hours for her ADLs (activities of daily living), and the requested increase is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient stay. 
The denial is upheld.

The patient is a male with no significant past medical history who presented to the hospital seeking detoxification from alcohol. The patient stated that he had been drinking heavily for 5 years and consumed approximately 1 pint of liquor daily. The patient had never been hospitalized previously due to alcohol-related problems but was seen in the emergency department for evaluation of chest pain when he was intoxicated. At the time of admission, the patient estimated that his last drink was approximately 36 hours before he came to the hospital.
When seen by the admitting physician he complained of nausea, tremors, abdominal cramping, lower extremity numbness and tingling, mild anxiety, and mild psychomotor agitation as well as occasional sweating.
At the same time, the patient denied fever, chills, headaches, chest pain, shortness of breath, hallucinations, suicidal ideation (SI)/homicidal ideation (HI). In the emergency department, the patient received treatment with Librium, potassium, and magnesium supplements.
When seen by the admitting physician he was afebrile. His pulse rate was 100 beats per minute (bpm), respiratory rate 18 breaths/min, and blood pressure was 153/116.

The patient was admitted to the hospital with a diagnosis of alcohol dependence with withdrawal. CIWA (Clinical Institute Withdrawal Assessment Alcohol) protocol was initiated utilizing Ativan, multivitamins, thiamine, folic acid, and B12. He was evaluated by physical medicine and rehabilitation (PM&R) service for ataxic gait. During the hospital stay his clinical condition gradually improved. Therefore, he was discharged home with a recommendation to abstain from alcohol. The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
This patient had relatively mild symptoms of alcohol withdrawal. Even though his heart rate was greater than 100 bpm, there was no evidence of persistent nausea, vomiting, tremor, or increased perspiration in conjunction with other high-risk features such as a history of delirium due to alcohol withdrawal. There were no reported seizures.
Furthermore, there was no history of significant medical conditions such as severe cardiac disease or any other unstable clinical conditions due to alcohol withdrawal.
Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of services provided required admission at the acute inpatient level of care.
Overall, he remained in stable clinical condition and his alcohol withdrawal symptoms were relatively mild.
There were no unstable medical conditions requiring evaluation or treatment at the acute inpatient level of care.
The hospital stay could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

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

The patient was brought to the emergency department (ED) with a mass growing on the back of his neck for two days that had increased to the size of a golf ball. His mother said that it was mobile, not tender or warm. There was no fever or any symptoms. In the ED, a common birthmark was noted at the neck hairline that his mother said was present since birth, as well as a 4x3 centimeter (cm) round mass on the upper third of the posterior surface of the neck without surrounding erythema; it was soft, mobile, and cystic in consistency. An ultrasound showed a fluid filled cyst. Magnetic resonance imaging (MRI) showed a multiseptated lesion in the suboccipital region extending to the right parotid region. The patient was admitted to the hospital. The admitting differential diagnosis was lymphangioma, lymphoma, cystic hygroma, neuroblastoma. His mother expressed preference for care at a different medical center and the baby was discharged the next day. The baby was completely stable during the admission and did not require any interventions.

At issue is the medical necessity of an inpatient hospital stay.

No, the inpatient hospital stay was not medically necessary.

The patient had already been fully evaluated with radiographs prior to admission and did not have a condition that required urgent/emergent management. The presenting clinical problem was an outpatient issue, to be further worked up as an outpatient rather than an inpatient, because the baby was completely clinically stable and did not require any interventions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) COVID-19 infection. 
Treatment: Increase Personal Care Level 2 To 8 Hours Per Day, 7 Days Per Week, Total 56 Hours Per Week. 
The insurer denied the  Increase Personal Care Level 2 To 8 Hours Per Day, 7 Days Per Week, Total 56 Hours Per Week. 
The denial is overturned. 

The patient is a male. He reportedly has significant residual weakness and functional decline after COVID-19 infection. The patient has osteoarthritis with joints stiffness. The request is to Increase Personal Care Level 2 To 8 Hours Per Day, 7 Days Per Week, Total 56 Hours Per Week. 

The health plan's reason for prior denial was that the requested increase is not medically necessary. 

Yes, the requested Increase Personal Care Level 2 To 8 Hours Per Day, 7 Days Per Week, Total 56 Hours Per Week is medically necessary. 

The patient has significant weakness, limited mobility and functional decline after COVID-19 infection. The patient also has memory deficits. The patient has had multiple hospitalizations for COPD (chronic obstructive pulmonary disease) exacerbations. 

The patient has underlying depression and urinary and fecal incontinence. The patient requires multiple diaper changes both during day- and night-time. The patient has unsteady gait and is high risk for falls and injuries. 

The patient needs help with ADLs (activities of daily living) and constant reminders and supervision. He needs help with meal preparations and needs reminders for medication. 

The patient requires multiple diaper changes both during day- and night-time. Patient is fall risk and 33 hours/week would not be sufficient to ensure safety. 

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

Patient has significant functional decline and needs constant supervision and monitoring.