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

Diagnosis: Pneumonia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient is an adult with a past medical history significant for bronchiectasis and resolved COVID pneumonia who presented to the emergency department with complaints of congestion and cough. 

Vitals on presentation were normal and oxygen saturation on room air was 99%. Laboratory values were notable for the following: White blood cells (WBC)-9.0, Hemoglobin (Hgb)-14.0, Hematocrit (Hct)-42.6, creatinine-0.69, and glucose-94. 

The patient was admitted to the hospital for possible pneumonia. A chest x-ray showed right middle lobe atelectasis with bronchiectasis with "slight worsening of the right middle lobe infiltrate" compared with prior examination. She was started on antibiotics (ceftriaxone) and nebulizer treatments. The patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management on oral antibiotics. 

The patient presented with complaints of cough. Otherwise, she was afebrile, hemodynamically stable with normal oxygen saturation. Laboratory findings were unremarkable including normal WBC and negative viral respiratory panel.  The patient was described as--"she does not appear ill, no distress." Based on the above findings, the patient met criteria for observation level of management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza A.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
Patient is an adult with past medical history significant for hypertension, hyperlipidemia, transient ischemic attack, cerebral vascular accident, migraines, asthma, and chest tightness who presented to the emergency department with complaints of fever, headache, dizziness, shortness of breath, and abdominal pain. 

Vitals on presentation included: Temperature 99.0 degrees Fahrenheit, Blood Pressure 152/83, Pulse 95, Respiratory 20, oxygen (O2) saturation 97% on Room Air.  Laboratory results showed the following: white blood cell count (WBC) 13.2, Hemoglobin (Hgb)-12.3, Hematocrit (Hct)-39.7, creatinine-0.58, glucose-111.

Patient was admitted for influenza A infection. She was started on Tamiflu, steroids, and nebulizer treatments. Chest x-ray (CXR) was negative, and echocardiogram was normal. Patient remained afebrile, hemodynamically, and clinically stable. She was discharged to continue follow-up as an outpatient.

According to medical records, patient presented upper respiratory infection-like symptoms and tested influenza A positive. Otherwise, she was afebrile, hemodynamically stable with unremarkable laboratory results except for a mildly elevated WBC. There was no evidence of a disseminated infection. CXR was normal. Based on above findings, patient met criteria for observation level of care.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cancer
Treatment: home health care
The insurer denied personal care services. The health plan's determination is upheld. 

This is a case review for a female with medical history notable for pancreatic cancer, depression, anxiety, diabetes, hypertension, and obesity. The patient and her care team requested an increase to 5 hours per day, 7 days per week (35 hours per week).
The request states that the patient is undergoing chemotherapy and is now easily fatigued. She is having difficulty performing her activities of daily living (ADL) and Instrumental activities of daily living (IADL) since starting chemotherapy.

The requested Personal care assistance services are not medically necessary for this patient.
The patient's Uniform Assessment System (UAS) demonstrates some need for assistance with Instrumental activities of daily living (IADL) but shows that she is independent with activities of daily living (ADL). She lives with her son and husband who also provide informal support for IADL's. There is no documentation of unmet personal care needs that would warrant an increase in personal care services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dentofacial deformity.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned.

This patient is an adult who was under the care of an Oral and Maxillofacial Surgeon (OMS) for her dentofacial deformity. The patient underwent orthognathic surgery to treat this condition under general anesthesia. The patient underwent a LeFort 1 and bilateral sagittal split osteotomy (BSSO), turbinectomy, and septoplasty. The patient required a one-day inpatient stay. The treating provider is requesting plan coverage of the inpatient stay, which is under medical necessity review.

This patient underwent surgery with general anesthesia and had shortness of breath postoperatively. The surgeon had concerns of airway patency, swelling, and urination concerns. The patient required a one-day inpatient stay. Surgical treatment for maxillofacial deformities are listed as conditions that are eligible for inpatient admission per Milliman Care Guidelines (MCG) Health Head and Neck Surgery or Procedure. 

"Orthognathic surgery is a unique endeavor in facial surgery: Both facial appearance and occlusal function can be improved to enhance a patient's sense of well-being. In today's orthognathic surgery practice, a close collaboration between the surgeon and the orthodontist -with careful treatment planning- leads to predictable and reproducible surgical outcomes. Standard orthognathic procedures, such as a LeFort 1 maxillary osteotomy and bilateral sagittal splitting of the mandible may be combined with adjunctive procedures to correct hard and soft tissue contours. Virtual planning of the operation and operative steps allows for more exact preoperative preparation, as well as for more thorough and interactive preoperative patient education." (Khechoyan D. Y. 2013).

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 full inpatient hospital admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

The patient is a female with chronic low back pain. Prior treatment has included chiropractic care, injections, physical therapy, as well as medications, which include Advil to Mobic. Pain ranges from 9 out of 10 through 10 out of 10. Pain impacts her activities. Magnetic resonance imaging (MRI) lumbar spine shows Modic changes at L (lumbar)5, S (sacral) 1 vertebral bodies.

The proposed Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed treatment is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a female patient diagnosed with low back pain. Records provided note that the patient was recommended to undergo the Intracept procedure (Intraosseous Basivertebral Nerve Ablation Procedure).

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, the patient's magnetic resonance imaging (MRI) shows multiple findings that are likely pain generators including facet arthropathy, spondylolisthesis and disc bulging with moderate to marked bilateral foraminal narrowing. This procedure remains experimental and investigational as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a female who has chronic low back pain. Her pain is constant sharp stabbing with numbness. She had tried physical therapy (PT) and pain medications without adequate improvement. Pain level is 9/10. She has radiating pain to the left leg. Magnetic resonance imaging (MRI) showed L (lumbar) 4/5 facet arthropathy, L5/S (sacral)1 spondylolisthesis with moderate facet arthropathy and moderate to marked bilateral foraminal narrow, chronic endplate deformity, fatty deposition in the subcortical marrow. Physical exam (PE) was unremarkable with 5/5 motor strength in BLEs (bilateral lower extremities), pain with lumbar flexion and positive Kemp. This patient was recommended for right L5/S1 transforaminal epidural injection and Intracept Intraosseous nerve ablation.

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has back pain and numbness with radiating pain to the left leg. PE documented positive Kemp test. MRI revealed L5/S1 spondylolisthesis with moderate facet arthropathy and moderate to marked bilateral foraminal narrow. Truumees's study supported the efficacy of Intracept procedure vertebrogenic back pain. However, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.
Given this patient's medical history, MRI reading, and the current clinical evidence, it is unlikely that the proposed Intracept Procedure is likely to be more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
Treatment: Inpatient Emergency Admission
The insurer denied the inpatient emergency admission.
The health plan's determination is upheld.

The patient is a male with hypogammaglobulinemia who presented to the emergency department (ED) with vomiting and diarrhea. His symptoms began 1 day prior to admission. Additional symptoms included fever to 101.7 degrees Fahrenheit, cough, congestion, decreased activity and decreased urine output.
In the ED his vital signs were temperature 38.1 degrees Celsius, heart rate (HR) 149, respiratory rate (RR) 36, blood pressure (BP) 101/60 and his peripheral capillary oxygen saturation (SpO2) was 97 percent (%) room air. The examination noted that the patient was tired appearing with nasal congestion and scattered wheezes. 

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

The requested inpatient emergency admission is not considered medically necessary for this patient. The patient presented with vomiting and upper respiratory infection (URI) symptoms. The laboratory studies were significant for a bicarbonate of 15 and positive urine ketones. The Flu, Coronavirus (COVID), and respiratory syncytial virus (RSV) tests were negative. The patient was diagnosed with acute viral illness and was admitted to the hospital for the management of dehydration. His condition improved with intravenous fluids (IVF) and he was discharged home the next day.
He was found to have moderate dehydration. He tolerated sips of juice in the ED. Based on the patient's condition and response to ED treatment, he could have been cared for at an alternate level of care rather than full inpatient admission.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mobility Issues.
Treatment:  Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per Week.

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of irritable bowel syndrome, chronic hyponatremia, urinary incontinence, bowel incontinence, atrial fibrillation with chronic anticoagulation, hyperlipidemia, hypertension, transient ischemic attack (TIA) / cerebrovascular accident (CVA), dementia, coronary artery disease, anxiety, and vitamin B12 deficiency, who had been assigned Home Care/Personal Care HHC services.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per Week are medically necessary for this patient.

The patient's medical provider documented decline in the patient's functional status and recommended an increase in HHC hours. The patient's telephonic assessment likely underestimated the patient's care needs, as the patient's daughter and medical provider documented worsening functional status even though the assessment documented decreased assistance needs with tasks of managing medication, phone use, stairs, transportation, walking, and transfer toilet when compared to previous assessment. The patient requires at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use, and therefore has unpredictable and unscheduled care needs that span a continuum of time, and the insurer failed to document a plan to meet the patient's unpredictable and unscheduled care needs. The patient requires assistance outside of the time she has informal help. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in home care/personal care HHC is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care/Personal Care HHC- Level 2 Personal Care Services 60 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right femur intertrochanteric fracture
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is an adult with a history of multiple sclerosis and hypertension. The patient presented to Lenox Health Greenwich Village emergency department (ED) following a fall and was diagnosed with a right femur intertrochanteric fracture. The patient was transferred to Lenox Hill Hospital for surgery to restore length and alignment to the limb and facilitate functional rehabilitation. The patient underwent intramedullary nail fixation of right femur intertrochanteric fracture. 

The medical records substantiate necessity of acute level services. This person sustained a major orthopedic injury. A hip fracture requires urgent surgical management and preparation. The records show transfer from one institution to another for the procedure which requires general anesthesia. There is associated blood loss and hematological monitoring is required. The procedure is painful and parenteral analgesia is necessary. Rehabilitative services have to be provided prior to discharge. The procedure is not ambulatory nor in any sense elective. One cannot predict the best proposed outcome for this clinical scenario. 

The inpatient admission is considered medically necessary for this patient.

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: Tubo-ovarian abscess

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient was diagnosed with a  tubo-ovarian abscess  (TOA) based on leukocytosis, abdominal pain, computed tomography (CT) and ultrasound findings. TOA is a serious and potentially life-threatening condition. Aggressive medical and/or surgical therapy is required, and rupture of an abscess may result in sepsis. For patients with ruptured abscesses, current mortality rates may be as high as 1.7 to 3.7 percent. 

It is agreed that the presence of a TOA requires hospital management initially. Experts agree that women with a TOA should be treated as an inpatient with intravenous antibiotics, at least initially. This is consistent with the recommendation by the United States Centers for Disease Control (CDC). This patient presented with abdominal pain, elevated white blood cells (WBCs) and CT and ultrasound findings consistent with a TOA. She was admitted according to the standard of care and the CDC recommendations. Once the patient was deemed stable with an improvement of her symptoms she was discharged home. 

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

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is a teenager with a history of asthma. The patient presented to the hospital with complaints of shortness of breath (SOB), chest tightness, and wheezing for 5 days. The patient had presented to the hospital 2 days prior to this arrival and was found to have Influenza. The patient was discharged home on oral (PO) prednisone.

At presentation to emergency room (ER) temperature was 100.3 degrees F, respiratory rate was 20 breaths per minutes, and blood pressure was 118/77. Oxygen saturation was 96% on room air. The patient was in no apparent distress and there was no use of accessory muscles. The patient was able to speak in full sentences. There was some wheezing. The patient was alert and oriented (A+O) x 3. White blood cell (WBC) count was 7.6 and electrolytes were within normal limits (WNL). Venous blood gasses (VBG) pH 7.39/PCO2 42. A chest x-ray (CXR) revealed no acute infiltrates. Influenza A testing was positive. 

The patient was admitted to hospital with influenza A and an asthma exacerbation.
The patient was treated with intravenous (IV) Steroids, Magnesium, Duo Nebs and Tamiflu. The patient improved with treatment and remained stable after admission. The patient was afebrile and hemodynamically stable within 24 hours. Oxygen saturation was 97 % on room air. The patient's lungs were clear. The patient was cleared for discharge home on oral (PO) medications.

The patient remained stable after admission. The patient was tolerating PO intake. The patient was not hypoxic. There was no pneumonia on the CXR. This patient did not need an acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. The patient could have been placed under observation. The patient could have been discharged home on PO medications.

Based on the above, the insurer's denial must be upheld. 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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Vomiting and Diarrhea
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a young male with no known significant medical history that presented with fever to 100.4 degrees Fahrenheit, vomiting and diarrhea. The patient had dry cracked lips and appeared ill in the emergency department. The patient was admitted for intravenous fluids and monitoring of vitals and labs until the patient was taking good oral intake (PO) and was ready for discharge.

The patient did not have a high fever as the maximum documented temperature was 100.4. The patient's bicarbonate of 18 was not demonstrative of moderate to severe dehydration. The patient did not have ketones in the urine, nor did the patient demonstrate abnormal kidney function or any demonstration of muscle breakdown, such as rhabdomyolysis. The patient did not have an initial concern for underlying surgical issues of obstruction or appendicitis as documented by imaging in the emergency department (ED). The patient did not have documented failed oral challenge with Zofran noted. The patient had no other symptoms involved. The patient had no blood in their stool or emesis. As the patient displayed as having viral gastroenteritis with no symptoms of other underlying pathology relating to a surgical issue, renal dysfunction of any other pathologies, the patient could have been admitted for observation initially.
 
The admission for inpatient level of care was not medically necessary. The plan did act in the best interest of the patient.