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

Diagnosis: Coronary Artery Disease, Congestive Heart Failure
Treatment: Personal Care 7 days per week 12 hours per day (or 84 hours per week)
The insurer denied Personal Care 7 days per week 12 hours per day (or 84 hours per week).
The determination is upheld.

This is a male patient with a medical history notable for coronary artery disease, congestive heart failure, and hypertension. The patient was receiving 12 hours per day, 7 days per week (84 hours per week) of personal care assistance. The health plan reduced the patient's hours to 8 hours per day, 7 days per week (56 hours per week). This reduction is being appealed by the patient.
A Uniform Assessment System was completed. The patient lives alone in an apartment. He was alert and oriented. He is able to direct all of his own care and is able to call for help in an emergency. For his instrumental activities of daily living, the patient requires total dependence for housework. He requires maximal assistance for meal preparation and shopping. He requires extensive assistance for transportation, stairs, and medications. For his activities of daily living, he requires extensive assistance for dressing lower body and toilet use. He requires limited assistance for eating, hygiene, dressing upper body, walking, locomotion, and toilet transfer. He is independent for bed mobility and eating. He has an unsteady gait with fair balance and ambulates with a cane. He is infrequently incontinent of urine and is continent of stool. There were no falls in the previous 90 days. There was no pressure ulcer present. A task tool associated with the assessment recommended 33.4 hours per week to address his personal care needs. Compared to a prior assessment, the patient showed an improvement in functional status, as he previously required extensive assistance for nearly all activities of daily living. There were no medical records or letters of medical necessity provided as part of this appeal. At issue is the medical necessity of Personal Care 7 days per week 12 hours per day (or 84 hours per week).

The requested health service of Personal Care 7 days per week 12 hours per day (or 84 hours per week) has not been demonstrated to be medically necessary for this patient.
The patient requires some assistance with instrumental activities of daily living and activities of daily living. He is approved for 8 hours per day, or 56 hours per week which is more than the 33.4 hours per week recommended by the task tool. There was no documentation regarding which personal needs, if any, would not be met at this level of personal care. The patient is able to direct his own care and can use these hours as he sees fit to meet his personal care needs. Therefore, the requested increase has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.
 

According to the documentation submitted and as per the triage note, this is an adult who presented to the emergency department (ED) with right lower quadrant (RLQ) pain that started the previous night associated with nausea. The patient denied fever or chills.  On exam, he was afebrile with stable vital signs. The patient was not in any acute distress. Labs and computed tomography (CT) were ordered. The ED provider noted that on exam the patient's abdomen was tender in the RLQ. There was guarding and rebound and McBurney's sign. The assessment was possible appendicitis versus pancreatitis or infectious process.

Surgery was consulted and noted the patient to have acute appendicitis and plan for laparoscopic possible open appendectomy. The White blood cell (WBC) count was 17 and the CT showed acute appendicitis. The patient was given intravenous (IV) Zosyn.

The ED disposition note indicated the encounter diagnosis of acute appendicitis with localized peritonitis, without perforation, abscess or gangrene.

The patient was taken to the operating room and underwent an uneventful laparoscopic appendectomy for acute appendicitis without perforation, abscess or gangrene.

Post op check indicated the patient was doing well, tolerating diet. The plan was for discharge.

Progress notes indicated the patient had a fever to 102 degrees F and complained of chills. He was able to ambulate and tolerated a diet. The plan was to observe as the patient had a clear base of the appendix at the time of surgery. The plan was to discharge in the morning as long as stable.

Based on the above, the insurer's denial must be reversed. 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: Upheld

Diagnosis: oxygen desaturation

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is a child admitted after oxygen desaturation during Magnetic Resonance Imaging (MRI). There was no documented need for intubation, continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC). The desaturation was transient and treated with oxygen and supportive care.  There was pre-anesthesia checkup for dental work and the patient was cleared. No antibiotics were needed. No fever was reported. There was no overdose of sedatives documented. Vital signs were normal in the emergency department (ED). The Oxygen Saturation was 90 percent and above. The patient could have been observed for a few hours in the radiology suite and sent home. Chest X-ray (CXR) was not done, and home meds were continued. The patient's respiratory status continued to be normal in the hospital. 

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 an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip and low back pain
Treatment: Physical Therapy (18 visits) 
The insurer denied Physical Therapy (18 visits). 
The denial is upheld.

The patient is an adult male with a history of a congenital heart defect status post repair who is now a competitive runner. He developed pain in the left thigh. He has had persistent pain despite medications, injections, physical therapy, and surgery. He was referred for physical therapy last year. The continued therapy was denied coverage by the health plan and is the subject of review.

The Physical Therapy (18 visits) were not medically necessary.

The patient has had a long history of treatment for hip and low back pain. He was referred for physical therapy specifically for lumbar radiculopathy last year. Despite ongoing therapy, he continues to report pain in the low back and hip along with limited range of motion and strength in this region. As of last year, further improvement in a reasonable and predictable amount of time was not expected. He was able to transition to a home exercise program at that time. A study on a home exercise program for neuropathic pain from a lumbar disc herniation concluded (1), "The intention-to-treat analysis showed a statistically significant difference in neuropathic pain, patient global assessment, low back pain, disability, and function in favor of the yoga group at post-treatment." The continued therapy was not medically necessary, as the patient's needs could have been met in a less intensive setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Ankle Fracture

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is a patient who fell in the shower. The patient reported left ankle pain. The patient was evaluated in emergency department (ED). The patient had several underlying medical conditions including depression, diabetes, chronic obstructive pulmonary disease (COPD), and a previous pulmonary embolism (PE). The patient had previous cardiac problems with stents. 

The patient is a smoker with body mass index (BMI) of 42. The patient required subspecialty consultation and several imaging studies. The patient was American Society of Anesthesiologists (ASA) class 3. 

The patient underwent surgery two days after admission. The patient's post-surgical course was complicated by anxiety, necessity for pain medications and electrolyte problems. The patient was discharged seven days later.

The medical records show the patient has several underlying medical conditions which support the level of services provided. The patient's elevated BMI, in the presence of smoking, cardiac disease and previous PE place them at extremely high risk for complications. The patient required several subspecialists to assist in management, including psychiatry, orthopedic, and nephrology. The patient had problems with mobilization and pain relief. 

Based upon the complexity of the patient's unique clinical circumstance, services could not be provided at a lower level of care. 

Based on the above, the insurer's denial must be reversed. 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 a full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dental caries

Treatment: root canal on tooth # (number) 12

The insurer denied coverage for root canal on tooth #12

The denial is overturned.


Based on the submitted documentation which includes copies of pre-endodontic therapy full mouth series radiographs, dental charting and treatment record from Great Expressions dental, narrative letter from patient, referral note and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment.

Endodontic therapy was recommended on tooth #12 due to carious lesions encroaching on the pulp spaces. 

Upon review of radiographs, they support the recommended treatment. Tooth #12 has carious lesion involving the pulp chambers radiographically and exhibits a widened periodontal ligament space consistent with incipient periapical pathogenesis secondary to caries. This would require endodontic therapy as recommended by the dentist. The standard of care in general dental practice would be endodontic therapy for this tooth which would have an excellent long-term prognosis with the recommended treatment.

A root canal on tooth #12 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 root canal on tooth #12 services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis

Treatment: Remicade Injections,10 milligrams (mg)/kilograms (kg) every 8 weeks.

The insurer denied coverage for Remicade Injections,10 milligrams (mg)/kilograms (kg) every 8 weeks.

The denial is overturned.

 
The patient has ulcerative colitis. The patient has been on treatment with Remicade but remains with ongoing symptoms. lnfliximab trough levels were low and no antibodies were detected. The patient's physician is advising to increase the infliximab to 10 milligrams (mg)/kilogram (kg) every 8 weeks. 

According to the American Journal of Gastroenterology (2010), the conclusion was that measuring infliximab concentrations and antibody levels is clinically useful. Increasing the drug dose may be a good strategy if infliximab levels are subtherapeutic. 

According to Clinical Gastroenterology and Hepatology (2019), the conclusion states that consensus was achieved towards the utility of therapeutic drug monitoring of biologics in irritable bowel disease (IBD), particularly anti-tumor necrosis factor (TNF) therapy. For anti-TNF therapies, proactive therapeutic drug monitoring was found to be appropriate after induction and at least once during maintenance therapy. 

According to Digestive Disease Sciences (2015), the conclusion was that dose escalation during maintenance enabled recovery of response in the majority of patients. 

This patient has ulcerative colitis and had some improvement with infliximab standard dosing but now has low therapeutic levels and persistent disease activity. The medical literature supports the dose escalation of infliximab to 10 mg/kg every 8 weeks. The health care plan did not act with sound medical judgment. Giving Remicade 10 mg/kg every 8 weeks is medically necessary. The denial is reversed.

Based on the above, the insurer's denial must be reversed. 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 Remicade Injections, 10mg/kg every 8 weeks is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with history of asthma, anxiety, human immunodeficiency virus (HIV), and chronic pain. She presented to the emergency room with worsening shortness of breath. The patient had had multiple asthma exacerbation admissions in the prior 12 months. The patient had been on chronic oral prednisone that she stopped taking and started having worsening symptoms. The patient was admitted to the hospital for asthma exacerbation. The patient was started on intravenous steroids and Duonebs. She continued to receive intravenous opioids for pain. The acute hospitalization was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The inpatient admission was not medically necessary.

The patient was admitted to the hospital for the management of an asthma exacerbation. The patient was started on oral prednisone, as well as Symbicort, Singulair and Duonebs. The patient also had worsening chronic pain and was started on intravenous morphine. On day # (number) 2, the patient was seen by pulmonary consult team, and their recommendation was to continue oral prednisone. By day #3, the patient's asthma symptoms were improving, and she was receiving pain medications. The patient's pain was better controlled by day #4. The patient was seen by physical therapy on day #5 and was recommended to be discharged home. The patient remained in the hospital from day #5 to day #8 for social disposition. The patient had prolonged hospitalization despite significant improvement in symptoms within 48 hours of admission. The patient did not require supplemental oxygen. The patient was not on any invasive drips. The patient was hemodynamically stable. The patient's asthma symptoms were at baseline by day #3 and pain was better controlled. The patient did not receive any treatment that could not have been safely and effectively be provided at a lower level of care. The requested hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Upper Extremity Wounds
Treatment: Inpatient Admission

The insurer denied inpatient admission.
The denial is overturned.

This adult male presented to the hospital with bilateral upper extremity wounds and redness with foul drainage. He had a history of injection drug use. On presentation, the patient had extensive ulcerations of both upper extremities without neurovascular compromise. The patient had normal vital signs and routine labs but had an elevated C-reactive protein (CRP) of 19 and an erythrocyte sedimentation rate (ESR) of 87. The patient was started on intravenous antibiotics and admitted to the hospital. Blood cultures obtained in the emergency room turned positive for methicillin-sensitive Staphylococcus aureus (MSSA). He had computed tomography (CT) scans of both upper extremities, showing no abscess but extensive ulceration. The patient received appropriate coverage with antibiotics and local wound care. He was ultimately discharged on oral antibiotics with instructions to follow up in the wound care center. The basis for the denial was the fact that the patient's condition did not meet Milliman Care Guidelines (MCG) 26th edition criteria for cellulitis. The primary basis for the appeal is that the patient had bacteremia.

The requested health service was medically necessary.

The patient had a history of intravenous drug use. He not only had cellulitis of both upper extremities but also large wounds on both upper extremities. He was having withdrawal from opiates and had a blood culture positive for Staphylococcus aureus (SA). Additionally, the patient's ESR and CRP had elevated, and all the findings were consistent with the idea that debridement and long-term antibiotic treatment would be needed, in addition to an echocardiogram (ECHO) and repeat blood cultures. The patient's condition was not simply that of uncomplicated cellulitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Displaced Tibial Tubercle Fracture

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is an adolescent patient who sustained an accident in the school gym. The patient was evaluated at the hospital and diagnosed with a left displaced tibial tubercle fracture. The patient did not have associated medical conditions nor other complaints. The patient underwent an open reduction internal fixation (ORIF) to the tibia tubercle on the day of admission. The patient's post-surgical course was uncomplicated. The patient was discharged two days later. 

The records show the diagnosis was not complex nor extensive. The injury was isolated. The mechanism of accident was low energy. There were no other medical conditions present. The surgery completed was of limited duration. The operation was approximately one hour with no significant blood loss. A limited incision was created with placement of 3 screws. 

The postoperative course noted normal vital signs, no bleeding, no problems with the wound and the patient had the ability to tolerate oral pain medication (Tylenol, Ibuprofen). There was no need for additional imaging or specialty consultation. There were no delays in physical therapy/ambulation. 

The reported need for durable medical equipment (DME) would not substantiate necessity of inpatient admission. There were no extenuating circumstances requiring the level of care provided.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Systemic inflammatory response syndrome (SIRS)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is partially approved.

The patient is an adult male. He presented to the hospital with bilateral hand numbness, vomiting, dizziness, abdominal pain, urinary frequency, and chest pain. The patient's vital signs were stable: temperature 100.8, respiratory rate 17, heart rate 116, blood pressure 100/53, and oxygenation 96% (percent). His exam was unremarkable. His hand numbness had resolved. Remarkable labs: white blood cell count 16.6, hemoglobin 13, creatinine 1.12, lactic acid 2.9, sodium 129, and troponin negative. Urinalysis was positive for leukocyte esterase. Chest X-ray and head and abdominal/pelvic computed tomography (CT) scans showed no acute disease. Electrocardiogram (EKG) showed sinus tachycardia and no ischemic changes. The patient was admitted with systemic inflammatory response syndrome (SIRS). Plan of care included intravenous antibiotics and intravenous fluids. On day #2, temperature was 98.6, heart rate was 96, and blood pressure was 100/54. Intravenous fluids were increased to 125 cubic centimeters per hour for blood pressure. Plan was to continue intravenous antibiotics. On day #3 and day #4 vital signs were stable with normal blood pressure and afebrile. 
Cultures were negative. He continued intravenous antibiotics. He was cleared for discharge on day #5.

Inpatient hospital admission for day #1 and day #2 was medically necessary, however inpatient hospital admission for days #3, #4, and #5 was not medically necessary.

This patient was admitted with systemic inflammatory response syndrome. The patient presented with several complaints. The evaluation supported systemic inflammatory response syndrome: temperature over 100.4 degrees Celsius, heart rate greater than 90, and white blood cell count greater than 12. Systolic blood pressure was borderline at 100. Diagnostic studies revealed an abnormal urinalysis. These findings support inpatient admission for cultures, intravenous fluids and intravenous antibiotics. He continued to require intravenous fluid support for blood pressure on day #2. Inpatient hospital admission for day #1 and day #2 was medically necessary for further evaluation and management of systemic inflammatory response syndrome. As of day #3, he was hemodynamically stable and without evidence of bacteremia. The patient was stable for discharge. Inpatient hospital admission for day #3 to day #5 was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

The adult patient has ileocolonic Crohn's disease and had been on Remicade. His last dose of Remicade was 6 months earlier. The patient now presented with abdominal pain and worsening pyoderma gangrenosum. A computed axial tomography (CAT) scan a few weeks earlier showed inflammation in the right colon and terminal ileum. In the emergency room (ER) the patient was hypertensive and pain medications were given. A computed tomography (CT) enterography showed a possible stricture. The patient left the hospital against medical advice (AMA). 

Medical necessity was determined based on Milliman Care Guideline (MCG) guideline M-565 for Inflammatory Bowel Disease. Clinical indications for admission include hemodynamic instability, abdominal abscess, fistulizing Crohn's disease, toxic megacolon, intestinal perforation, intestinal obstruction, peritoneal signs, severe electrolyte abnormalities, severe vomiting, severe anemia with signs of cardiac ischemia, stage 3 acute renal failure, and bacteremia. The patient did not have these conditions. 

This patient has active Crohn's disease and was no longer on biologic therapy. He now requires more aggressive treatment of the Crohn's disease including restarting the biologic therapy. However, this could have been done on an outpatient basis. Intravenous (IV) hydration and pain medications could have been given in the emergency room (ER) with observation status. He did not receive any acute interventions. He did not meet Milliman Care Guideline (MCG) criteria for admission for Inflammatory Bowel Disease. 

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 an inpatient admission is not substantiated.