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

Diagnosis:  Appendicitis
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with history of hypertension and depression.  She presented with right Lower quadrant (RLQ) pain, diarrhea and nausea for three days.

The patient's initial vital signs demonstrated a Heart rate 99 blood pressure 112/84.  White count (WBC) was 17.4k.  Exam demonstrated generalized right sided abdominal pain with focal tenderness to RLQ, no rebound or guarding noted.

CT abdomen pelvis demonstrated acute appendicitis.  The patient was admitted started the IV antibiotics stable for discharge 48 hours later.

On the first hospital day, the patient was noted to have slept comfortably with improved pain and no fever, chills, nausea or vomiting.  Abdominal exam at that time was soft, non-distended and mild tenderness in the RLQ with no rebound or guarding.  The WBC count was trending lower at 13.3K.

Discharge on Hospital day #2 afebrile, soft abdomen, WBC 10K for a planned interval appendectomy.

The patient presented with signs and symptoms of acute appendicitis and no evidence of sepsis.  She was placed on appropriate intravenous antibiotics, and the decision was made to treat non-operatively.

Once the decision was made to treat non-operatively, this patient could have been managed a lower level of care, as there was no clinical signs symptoms of sepsis or other intra-abdominal catastrophe.

Nonperforated appendicitis, also referred to as simple appendicitis or uncomplicated appendicitis, refers to acute appendicitis that presents without clinical or radiographic signs of perforation (e.g., inflammatory mass, phlegmon, or abscess).

Most cases of appendicitis are not perforated at presentation.  For adult patients with nonperforated appendicitis, the recommendation is for timely appendectomy, either open or laparoscopically.  Antibiotics can be used to augment rather than to replace surgery.  For the past 120 years, appendectomy has withstood the test of time as a safe, effective, and definitive therapy for appendicitis.

Despite evidence that antibiotics alone may be sufficient for managing the initial presentation of appendicitis, many surgeons are against its routine use for adult patients presenting with uncomplicated appendicitis.  Many scholars feel that its routine application in clinical practice is premature because of many unanswered questions (e.g., patient selection, recurrent attacks, and missed neoplasm).  Antibiotics are an option for those who are unfit for or refuse surgery.

In this particular case, once the decision was made for nonoperative care, the patient could have been managed at a lower level of care and discharged home sooner based on both objective and subjective data.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mood Disorder
Treatment: Continued Inpatient Mental Health Stay
The continued inpatient admission was medically necessary.

Summary:
The patient is a male with a history of psychiatric illness and substance abuse.

The patient has a history of prior psychiatric hospitalizations and has been diagnosed with a mood disorder.  He has a history of suicide attempt by strangulation.  He has an outpatient psychiatrist and is prescribed antidepressant and antipsychotic medications.  He is medication non-adherent.  He lives with his sister and is a daily marijuana abuser.  

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of psychosis with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of aggressive or self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of immune thrombocytopenic purpura, spontaneous subarachnoid hemorrhage, bipolar disorder, and hypothyroidism. She presented to the emergency department with nausea and vomiting for 3 days, including one episode of blood in her emesis, one episode of watery diarrhea, and reduced oral intake. Vital signs were notable for blood pressure of 153/85 millimeters of mercury (mmHg). Lab results showed an elevated aspartate aminotransferase of 72 U/L; platelet count was normal. An x-ray of the abdomen showed a nonobstructive bowel gas pattern.
A Gastroenterology consultation recommended proton pump inhibitor therapy, ondansetron, abdominal ultrasound, and esophagogastroduodenoscopy. She had abdominal burning pain and tenderness documented in one note, and excellent sleep without abdominal pain, nausea, or vomiting or any new complaints per the hospitalist note. Lab results showed an elevated aspartate aminotransferase of 77 U/L and aspartate aminotransferase of 69 U/L. An esophagogastroduodenoscopy (with American Society of Anesthesiologists (ASA) score of III) showed Grade A esophagitis, diffuse gastritis, and duodenitis; biopsies showed chronic active gastritis in the body and antrum, and Helicobacter pylori. 

The health plan's determination is upheld. The patient presented with abdominal pain, nausea, vomiting, and diarrhea, as well as one episode of hematemesis. This was consistent with gastritis or gastroenteritis; however, there was no sustained tachycardia or hypotension, ongoing gastrointestinal bleeding, or evidence of pathology such as gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction [1-5]. Gastroenterology performed an endoscopy, which was appropriate; and found gastritis but no active bleeding, gastric outlet obstruction, or ulcer. She improved within two days of inpatient admission. 

All of the measures that were undertaken, including monitoring, antiemetic therapy, Gastroenterology consultation, and endoscopy, could have been performed without an acute inpatient level of care [2-5]. The patient had gastritis but was not found to have complications such as ongoing gastrointestinal bleeding, gastric outlet obstruction, ulcer, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction.
Appeal type: Medical necessity
Decision: Overturned

Trauma/injuries: Other
Inpatient hospital

The patient is a man who presented as a trauma alert status post falling from a bicycle. He reported that he was riding his bicycle when he collided with a gate or fence that he did not see. He reported pain over the bilateral antecubital regions with contusions. He denied drug use. Vital signs showed blood pressure 145/80, heart rate 95, and respiratory rate 17. On physical examination, heart was regular, breath sounds were normal, and he had a hematoma over the right elbow and below the left elbow. Cranial nerves were intact. Head computed tomography (CT) demonstrated small hemorrhagic contusion in the left frontal lobe. A CT of the abdomen was negative for acute findings. 

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient presented with trauma and did have a small hemorrhagic contusion that increased his risk for further bleeding, acute stroke, and seizures. Brain confusion with bleeding is not normally treated at the outpatient level of care because of the increased risk of neurologic complications. The patient did need inpatient management for the contusion, even though it was described as small, because of evidence of hemorrhage. He also needed repeat head CT, Neuro checks, and monitoring of cranial nerve function.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malpositioned Teeth
Treatment:  Dental/Orthodontic Procedure

The patient in question is a female presenting with a skeletal Class I malocclusion and mild spacing.  She has a significant anterior open bite.  She is treatment planned for 24-30 months of orthodontics to address the spacing and open bite, but the treatment has been denied due to lack of medical necessity.

The health plan's determination is overturned.  Braces are medically necessary for this patient.  Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion.  However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion.  Given the patient's malocclusion and the likelihood of significantly reduced masticatory function and digestive function, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion 

Treatment: Braces (D8080) and monthly periodic dental visits

The insurer denied coverage for Braces (D8080) and monthly periodic dental visits. The denial was reversed.

This patient is a male who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, asymmetric mandible, Class II canines, maxillary spacing and mandibular spacing, excessive overjet and anterior crossbite with gingival attachment loss (right mandibular canine). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary attaining only 12 points on review by internal reviewers.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient. Based on the above, the medical necessity for Braces (D8080) and monthly periodic dental visits is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; extra teeth
Treatment: Braces and monthly visits
The proposed braces and monthly visits are medically necessary. 

The patient has severe crowding of both her upper and lower teeth. She has multiple extra teeth (supernumerary) that need to be removed and then all the teeth aligned. Her upper canines are not in their correct position. This will cause severe tooth to tooth grinding during the patient's chewing cycle. This will cause wearing down of her teeth and/or fracturing of her teeth due to lack of canine guidance. The canines need to be in their proper places to aid in the proper meshing of teeth during chewing. This case is to be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Female infertility, unspecified
Treatment: IUI cycle

The IUI cycle is not medically necessary, as there is no proof of an improvement in health outcome.

This patient was diagnosed with polycystic ovaries and anovulation. The provider submitted a recent semen analysis that showed a good count, slight decrease in motility 34% and 3% normal morphology. This semen analysis was not repeated. The two other semen analyses submitted are three to four years old.

The patient conceived previously with Clomid and insemination and is requesting coverage for the same treatment.

It is obvious that the cause of this patient's inability to conceive is the fact that she is not ovulating. While the semen analysis showed a slight decrease in motility and normal morphology, that semen analysis was not repeated, and there is no real evidence of a male factor. Multiple studies have shown that the addition of IUI does not improve pregnancy rates. Therefore, it is recommended not to add routinely IUI in women undergoing ovulation induction with clomiphene.

The patient does not have unexplained infertility, minimal or mild endometriosis, diminished ovarian reserve, male factor infertility, or unilateral tubal factor infertility.

In summary, based on the standard of care, the requested IUI is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration and volume depletion

Treatment: Inpatient hospital admission

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

This patient is a female with nausea and vomiting and was noted to have an elevated creatinine likely due to dehydration and volume depletion.  Per the physical examination, the patient was not in distress.  She appeared sick and had chills.  Per the ED assessment, the lab results showed proteinuria and electrolyte abnormalities, and the computerized tomography of the abdomen was normal.  A computed tomography of the abdomen and pelvis was done.  She was started on intravenous fluid and empiric antibiotics, and her condition responded appropriately.  She was discharged.

Per Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for acute kidney injury, this patient does not meet the definition of acute kidney injury because she did not have a rise of creatinine of at least 0.3 mg/dl from baseline or a change in glomerular filtration rate (GFR) more than 50% compared to baseline or decreased urine output.  In addition, she did not have severely abnormal electrolytes, did not have signs of acute tubular necrosis or irreversible kidney damage and did not require renal replacement therapy.  She was hemodynamically stable and did not have signs of severe sepsis per international guidelines for management of sepsis.  There is no evidence-based literature that this patients' condition could not be managed safely under a lower level of care.  Therefore, the inpatient admission was not medically necessary.  The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Diagnosis:  Infection
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male whose inpatient admission is under review.  The patient has a history of HIV and asthma.  He presented with fever, nausea, diarrhea, and myalgias for three days.  He had fever to 100.5 in ED the day prior.  He had been sent home, but he returned after his symptoms worsened.  He had diarrhea 5x/day.

The patient was thought to be immunosuppressed and to have sepsis, along with his diarrhea.  He was admitted and treated with ciprofloxacin and Flagyl.  Stool testing revealed EAEC (Enteroaggregative Escherichia coli) and Shigella.  He improved over several days and was sent home.

The patient is immunosuppressed, with sepsis, including high fever, tachycardia, and hypotension.  Standard of care would dictate admission of such a patient to ensure close observation and treatment to avoid complications such as circulatory collapse, septic shock, and death.  When dealing with immunosuppressed patients, standard algorithms for sepsis may not work (1), and individual judgments need to be made based on the history, presentation, and data.  Outpatient treatment or observation in such a case could lead to adverse and unwanted outcomes.
Appeal type: Medical necessity
Decision: Upheld

Seizure
Inpatient hospital

The patient is a male with a past medical history significant for intravenous drug abuse and alcoholism who was recently discharged from the alcohol detox center. He presented to the emergency department after he suddenly developed seizure-like activity. Apparently, the patient accompanied his wife in the emergency department where she herself was waiting to be seen, when he suddenly developed seizure-like activity. On initial physical exam performed in the ER, the patient was afebrile, heart rate was 85 beats per minute (bpm), respiratory rate 12, blood pressure 94/58, oxygen saturation 93% on room air. The patient was clenching fists and posturing his legs. His pupils were equal, round, and reactive to light and accommodation with no nystagmus. The patient had moist oral mucosa, the cardiovascular exam was unremarkable, lungs were clear to auscultation bilaterally with no wheezing, rhonchi, or rails.

The health plan's determination is upheld. The inpatient stay was not medically necessary. According to the information obtained from the medical records, the patient developed seizure-like activity after smoking a blunt. At the same time, there was no strong evidence that the patient, in fact, had a seizure. First of all, the patient responded to noxious stimuli, which usually is not observed during a real seizure.
Secondly, the drop arm test was performed, and the patient was able to control his arm and did not hit the face. This was a very unlikely finding if the patient had a real seizure.
In addition to that, it was clearly indicated in the notes that the patient recovered from that spell and became alert and oriented quickly. The results of the laboratory studies and diagnostic tests were reassuring and did not point towards a serious medical problem. However, the clinical diagnosis was unclear at the time of the initial evaluation, therefore the admission for observation was definitely reasonable. Based on the information provided in the medical records, there was no strong evidence that the patient required admission at the acute inpatient level of care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia; deconditioning
Treatment:  PCA ten hours/day, six days/week, for a total of 60 hours/week 

The proposed treatment of an increase in PCA hours to ten hours/day, six days/week, for a total of 60 hours/week is deemed medically necessary. 

The patient is a female with a history of cognitive impairment secondary dementia and severe deconditioning.  For these reasons, she requires assistance with completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of personal care assistance (PCA), ten hours/day, six days/week, for a total of 60 hours/week for improved assistance with completion of the patient's ADLs.

This is a female with a history of cognitive impairment secondary dementia and severe deconditioning.  For these reasons, she requires assistance with completion of the majority of her activities of daily living (ADLs).  Furthermore, documentation from the patient's attending physician indicates that the patient is demonstrating progressive functional decline with worsening generalized weakness/deconditioning and severely underweight at 77 pounds.  For these reasons, the currently approved plan of seven hours/day, four days/week, for a total of 28 hours/week is insufficient to meet the patient's current medical needs.  Hence, the proposed treatment of an increase in PCA hours to ten hours/day, six days/week, for a total of 60 hours/week is deemed medically necessary for improved assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history significant for Parkinson's disease and sacral decubitus ulcer. Personal care aide services, level 2, 12 hours per day 7 days a week split shift for a total of 168 hours per week is requested. At issue is the medical necessity of the requested personal care aide services. 

The health plan's determination is overturned. The requested services are medically necessary. The patient has a stage IV decubitus ulcer which would require frequent turning. Medical necessity is met for split shift services due to the needs for repositioning. 

This is a patient with a past medical history significant for Parkinson's disease, dysphagia, pressure/sacral ulcer stage IV, tube feedings, chronic urinary incontinence and Foley catheter. The client tasking sheet noted that the patient required an average of 9.5 hours a day for a total of 66.5 hours per week. The patient is noted to be dependent on the nursing aide for all activities of daily living (ADLs) and Instrumental activities of daily living (IADL)s. The physician reports noted a stage IV decubitus ulcer with recommendations for frequent repositioning every 2 hours. These medical recommendations cannot be met with live-in aide services. Services require more frequent attention than a live-in aide can provide based upon recommended working hours and recommended nonworking/sleep hours.