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

Diagnosis: Urinary retention
 
Treatment: Inpatient admission, diagnostic testing, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This is a male with a past medical history of diabetes and hyperlipidemia. He presented to the emergency room (ER) with complaints of pain at the tip of the penis on urination, and voiding only small amounts of urine.  A foley was placed and the patient was admitted for urine retention.  MRI was negative for cord compression.  Urology consulted and an ultrasound of the bladder revealed thick walled bladder and cellules. Scrotal sonogram showed small epidermal cysts/bilateral hydroceles.  The patient improved.  Cultures were negative for infection and the patient was discharged home with outpatient follow-up.   

Per MCG Health Urologic Disease GRG, the patient fails to meet clinical indications for admission to inpatient care under subsection:  Acute urinary retention requiring inpatient care shows there is no evidence of the following : Retention not alleviated by Emergency Room (ER)/Observation level/care, Hemodynamic instability, Acute kidney injury (AKI) requiring inpatient care, Acute neurologic etiology (cauda equina), and dehydration or other complication not manageable with emergency or observation level care.

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

Diagnosis: Vaso-occlusive Sickle Cell Disease Crisis
 
Treatment: Inpatient admission for management of Sickle Cell  Disease Pain

The insurer denied coverage. The denial was reversed.

This is a teenage patient with sickle cell disease presented after waking at home with description of 10/10 pain.  Of note, the patient had at the time been recently discharged and described pain since that discharge.  The day of presentation the patient tried oral home analgesia without adequate relief and therefore was brought to the emergency department (ED) urgently via emergency medical services (EMS) for severe pain.  In the ED the patient received IV analgesia with some relief, but severe pain soon recurred.  Based on the patients' pain at that time, and known history, the patient was admitted to better manage pain.  It would have been unreasonable to expect that further management in the ED would have prevented hospitalization given the degree of pain, short duration of relief from IV analgesia, and persistence of pain with inadequate response to oral analgesia at home prior to presentation.  Hospitalization was within standard of care.

The insurer denied coverage for the inpatient hospital admission noting that the patient was admitted due to sickle cell anemia pain.  The insurer also stated that the patient did not meet criteria for admission because vital signs were normal. They added that they have no notes the patient was dehydrated, had blockage in the bowel or required immediate surgery that is usually not done as a same day surgery. They maintain the patient's care could have been given in the ER or observation area with outpatient follow up.

It is commonly understood and widely published that in children and young adults with sickle cell disease the description of pain is often the only sign of sickle cell crisis. As such, for a patient in whom ambulatory analgesia has not been sufficient, hospitalization for management of pain is standard of care. The patient's vital signs seeming "normal" are not relevant to this decision.  Hospitalization for management of pain with IV analgesia, IV hydration and to monitor for escalation of care as needed was within standard of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history of legal blindness, hypertension, hyperlipidemia, weakness, repeated falls and incontinence who sustained a left comminuted intertrochanteric hip fracture, for which she declined surgical treatment and has been bedridden since the hip fracture. The patient initially had 6.5 hours per day of Consumer Directed Personal Assistance (CDPAP) services totaling 45.5 hours. The patient's physician recommended an increase in hours in a letter, specifically noting that the patient required total assistance with all activities of daily living (ADLs) and required repositioning every 2 hours to promote circulation and prevent pressure ulcers. The patient had an increase in CDPAP services to 11.5 hours per day, 7 days a week to total 80.5 hours per week. The physician then wrote a letter reiterating the patient's past medical history and need for repositioning every 2 hours and the need for 24 hours per day care (in split shifts)/7 days a week to total 168 hours per week. The health plan denied this request, stating the patient had live in CDPAP services and had room for a live in aide because the patient had a 2 bedroom apartment. Per the Comprehensive Community Assessment Report, it was noted the patient lived with her daughter in a 2 bedroom apartment. However, per the daughter, who is the designated CDPAP for the patient, the patient lives in a one bedroom apartment. The patient's care management report also indicated the patient had a one bedroom apartment. In addition, the health plan reported there were no orders for 2 hour turning and no wound care was being provided. The health plan is denying the request for 24 hour-split shift CDPAP services/7days per week to total 168 hours as not medically necessary. The health plan's determination is overturned. CDPAP 24 hours per day in split shift, 7 days a week to total 168 hours per week are medically necessary for this patient. The patient lives in a one bedroom apartment and has a significant medical history of legal blindness, incontinence, weakness and bedridden status since the comminuted left intertrochanteric fracture. The patient requires total assistance for ADLs and mobility related ADLs. The patient is incontinent and given her bedridden status requires assistance with positioning, toileting and incontinence care. The patient requires this assistance during the overnight hours. The patient's physician felt the patient needed to have repositioning every 2 hours in order to promote circulation and prevent pressure ulcers. Because the patient lives in a one bedroom apartment she does not have room for a live in aide during the overnight hours and split shift 24 hour care/7 days a week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental decay
 
Treatment: Root canal, crowns

The insurer denied root canals, core buildup and crowns on teeth #s 7, 9 and 10. That denial was reversed.

Based on the submitted documentation which includes copies pre endodontic therapy panoramic and periapical radiographs, dental treatment records, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment.  Endodontic therapy was recommended on multiple teeth including 7, 9, and 10 due to large carious lesions encroaching on the pulp spaces and periapical pathology #7, with subsequent recommended treatment of full coverage crowns to be placed with core buildups as necessary. The insurer has denied these services stating that the services are not medically necessary as the patient is missing multiple teeth in the maxilla, additional teeth in the arch need treatment, these teeth in question can be extracted and a denture can be fabricated.  

The radiographs support the dentist's recommended treatment. All teeth (7, 9, and 10) have large carious lesions involving the pulp chambers radiographically (#7 with periapical pathology as well), requiring endodontic therapy as identified by the dentist.  All have adequate residual coronal structure for support of crowns and minimal periodontal alveolar bone loss.  The standard of care in general dental practice would be endodontic therapy for these teeth which would have an excellent long term prognosis with the recommended treatment. Further, standard of care in dental practice would be full coverage restorations on endodontically treated teeth with post and core as recommended. 

Coverage for root canals, core buildup and crowns on teeth #'s 7,9 and 10 was medically necessary as the clinical and radiographic documentation support these services, and these services would be a standard of care in general dental practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis 
 
Treatment: Inpatient admission, diagnostic evaluation and medication management

The insurer denied inpatient admission. That denial was reversed
This child with a known history of type I diabetes presented with vomiting, abdominal pain, headache, decreased oral intake. Beta hydroxybutyrate was elevated at 3.94 and urine ketones were large.  Bicarbonate was 15 and anion gap was 20. PH was 7.28 with a base excess of -10.2.  The patient was treated with intravenous hydration as well as insulin.  The patient's acidosis and ketosis cleared and the patient was discharged home on his insulin regimen.

Hospitalization for diabetic ketoacidosis is universally medically necessary.  Patients with diabetes and initially generally require Intensive Care Unit (ICU) level care.  In this case the patient's diabetic ketoacidosis was mild and did not require ICU level care.

The patient was admitted for treatment of diabetic ketoacidosis.  Discharge from the emergency department would've been unsafe as the patient had acidosis and large ketones and was dehydrated and had been vomiting.

The requested hospitalization is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical radiculopathy
Issue under review: Epidural spinal injection

Determination:
The epidural spinal injection is medically necessary.

The patient has a history of cervical radiculopathy.  The patient has failed conservative treatment and continues to actively perform conservative treatment in the form of home exercise.  According to the appeal letters and the office notes, the patient has done physical therapy.  The patient did have a previous epidural steroid injection with good results.  A recent MRI was ordered and was reviewed.  The patient is on opiate medications, and the treatment team are trying to limit the amount of opiate medications the patient requires.  Given the above, and given the fact that the patient has failed conservative treatment and is actively involved in a home exercise plan, the requested cervical epidural steroid injection is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever and diarrhea

Treatment: Inpatient admission, diagnostic testing and medication management

The insurer denied inpatient admission. That denial was reversed

The patient was brought from home to the Emergency Department of Flushing Hospital Medical Center at 09:08 for assessment of fever to 102.3, non-bloody diarrhea for one day, decreased intake, cough and congestion.  There was no associated nausea, vomiting, weight loss, dysuria, or bleeding. The mother had a recent upper respiratory infection.  The patient's vital signs on arrival were notable for heart rate of 180, a temperature 38.2C, a respiratory rate in the 30's and a room air oxygen saturation of 99%.  Her weight was 4.961 kilograms.  Her physical exam was notable for a well-developed, alert female in no apparent distress.  Her lungs were clear.  Her cardiac exam was unremarkable.  Her abdominal exam was notable for normal bowel sounds and was soft.  There was no tenderness to palpation, organomegaly, distension, rebound, or guarding.  Urinalysis was notable for a specific gravity <1.005/pH 6. It was dip positive for trace blood with microscopy notable for 0-3 white blood cells per high power field.  Nasal washings were negative for respiratory syncytial virus (RSV) and Influenza A/B. Cultures (blood/urine) were obtained and ceftriaxone was given. The child was reportedly refusing oral feeds.  The child was admitted to the inpatient service at 15:12.  The child's vitals were stable, but her physical exam showed a 4/6 systolic ejection murmur and she was considered lethargic and somewhat dry.  The child received a 90cc normal saline bolus followed by D5 12 normal saline at 20cc/hour.  A lumber puncture was performed with studies notable for no white blood cells, a cerebral spinal fluid (CSF) glucose of 51 and CSF protein of 63. The team discharged her home after cultures remained negative x 48 hours for outpatient follow-up. 

This patient presented with loose stool, fever, cold-like symptoms and a sick contact suggesting a viral illness.  However, given the potential for sepsis without obvious physical findings, the patient was treated with antibiotics awaiting culture results.  clearly this child, although well-appearing in the Emergency Department, was febrile to 38.2C, with a WBC < 5000, an elevated CRP and elevated procalcitonin.  This alone would justify the approach taken with cultures followed by antibiotics in the inpatient setting in accordance with the literature.  In addition, this child did not appear quite as well once in the inpatient unit with lethargy and poor tone, leading to a lumber puncture for CSF analysis.  Regardless of the lack instability and the reassuring physical exam at presentation, her laboratory assessment merited the inpatient setting for this febrile neonate. This patient did meet medical necessity criteria for acute care admission for antibiotics and hemodynamic monitoring.
Appeal type: Medical necessity
Decision: Upheld

At the time of admission, this patient was an infant that was discharged 1 hour prior to presentation with a diagnosis of otitis media and pneumonia. He returned to the hospital as his parents reported that he had a fever of 104 degrees F after they returned home. Parents noticed decreased activity, decreased appetite and a continued cough. The fever began 1 day prior and included a visit to their primary medical doctor (PMD) where he was sent home to monitor fevers. His mother was able to control the fevers with Tylenol, but then he developed a dry intermittent cough accompanied by a sore throat, runny nose, increased congestion, decreased activity, poor feeding and decreased urinary output. The exam in the ER documents rhinorrhea, left TM hyperemic bulging, no light reflex and lungs with effort normal. There was no accessory muscle usage, nasal flaring or grunting or respiratory distress. The health plan's determination of medical necessity is upheld. This patient was admitted for suspected pneumonia and poor PO intake. He did not exhibit any criteria that warranted inpatient admission. He was not in respiratory distress, had no documented hypoxia or need for supplemental O2, no tachypnea, no clinical signs of dehydration and his vital signs were stable apart from being febrile. This patient presented with fever, rhinorrhea, cough and poor PO intake. He was noted to have left otitis media and suspected pneumonia, although the CXR was officially read as negative. He had an uneventful hospital course with occasional fever spikes and improved as expected. He was never in respiratory distress or hypoxic. His vital signs were stable, apart from the fevers. His laboratory studies were unremarkable apart from the slightly elevated CRP. Therefore, inpatient level of care was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Osteoporosis
Nursing Services (including Private Duty Nursing)

The patient is a male with several ongoing medical problems. His past medical history is significant for hypertension, benign prostatic hypertrophy, osteoporosis, immature dysfunction, gait dysfunction and hydrocephalus.
This review is for the medical necessity of personal care worker services 7 days a week 12 hours a day for a total of 84 hours per week. The patient has been approved for 8 hours a day 7 days a week for a total of 56 hours a week.

The health plan's determination is upheld. The Request in Personal Care Worker (PCW) Services to 7 Days per Week/12 Hours per Day is not medically necessary for this patient. The amount of service hours already approved are sufficient to meet the patient's needs. The patient requires personal care services for ADLs (activities of daily living) and most IADLs (Instrumental Activities of Daily Living). The patient is able to ambulate with a Rollator walker indoors. The patient is alert and oriented with some forgetfulness but has had no significant change in cognitive status compared to previous assessment dated. The Uniform Assessment System (UAS) State of New York, Tasking notes that the patient requires a total of 4.7 hours a day of care and is currently receiving 8 hours a day of care. This was similar to tasking noted previously. A recent magnetic resonance imaging (MRI) showed moderate chronic microvascular ischemic disease along with possible moderate communicating hydrocephalus Recent Physician notes noted that the patient did fall, and this was attributed to unsteady gait and dizziness
The hours approved are sufficient to meet the patient needs. There are no additional needs noted in the medical records or the tasking that cannot be met within the allotted time. There is notation that the patient's gait is unsteady, and currently the patient was undergoing therapy according to the notes. Preventing falls or observation to prevent falls is not typically considered a separate task when not eating performed with any ADL or IADL.
Appeal type: Medical necessity
Decision: Overturned

The patient with past medical history significant for traumatic brain injury resulting in traumatic hydrocephalus and ventriculoperitoneal (VP) shunt, and seizure disorder as well as tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement, recurrent methicillin-resistant staphylococcus aureus (MRSA) pneumonia, stage IV pressure ulcer, benign prostatic hyperplasia (BPH), gastroesophageal reflux disease (GERD), hypertension (HTN), and hyperlipidemia (HLP), presented to the emergency department with fever and altered mental status. 

Labs drawn showed white blood cell (WBC) count 13.1, alkaline phosphatase 242, basic metabolic panel (BMP) within normal limits, and lactic acid of 1.2. Computed tomography (CT) of the head showed bilateral encephalomalacia and large subdural collection that was chronic and unchanged. Chest x-ray (CXR) showed pleural effusion and atelectasis. Given concerns for sepsis and bronchitis versus early pneumonia, and possible urinary tract infection, the patient was subsequently admitted to the hospital. The health plan's determination is overturned in whole.

The requested treatment of inpatient stay was medically necessary for this patient. This chronically ill patient with aspiration pneumonia accompanied by sepsis and altered mental status required treatment at the acute inpatient level of care. The patient's chronically ill status with tracheostomy, inability to clear secretions, ongoing chronic aspiration risk placed patient at high risk of decompensation when already presenting with sepsis. The patient required aggressive treatment with IV antibiotics to treat a resistant organism in addition to high intensity respiratory therapy and close monitoring of mental status. Acute inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of Major Depressive Disorder.  The patient came to see the PCP (primary care physician) and reported SI (suicidal ideations) for the past 2 weeks without a plan.  The patient was referred to the ED (emergency department) and evaluated.  The home medications were documented as:  Celexa 10 milligrams (mg) PO(by mouth) Q (every)/day, Gabapentin 400 milligrams (mg) PO three times a day (tid), and Bupropion 300 mg/day.  The patient was calm and cooperative while undergoing evaluation in the ED.  The patient was admitted and the primary admitting diagnosis was Major Depressive Disorder.  The patient reported that the patient stopped going to her appointments with mental health provider 3-4 months ago due to poor motivation.  The patient stayed at home, had increased need for sleep, and increased appetite with weight gain.  The patient could not understand why the patient was feeling depressed, since the patient had a lot of positive things in life, such as stable residence and relationship with the family.

The health plan's determination is upheld.  Prior to inpatient admission, the patient had worsening of depressed mood and noncompliance with her mental health f/u care.  The patient had passive SI 2 weeks prior, which was the reason for inpatient admission.  The patient denied SI/HI or psychotic symptoms during the entire inpatient stay.  The patient tolerated increase in Celexa.  The patient had worsening of depressed mood and passive suicidal ideation (SI).  The patient was evaluated and received medication management, as well as therapy.  The patient was not suicidal, homicidal or psychotic for at least 48 hours prior to the first date under review.  Therefore, the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Keinbock's disease, Non healing fracture

Treatment: Bone growth stimulator.

The insurer denied bone growth stimulator. That denial was reversed.

This patient sustained an injury to the left and right wrist after falling onto outstretched hands when she tripped over a sidewalk.  The patient was diagnosed with bilateral Keinbock's disease.  The patient's treatment history included physical therapy, bracing, medications, activity modifications, a home exercise program, and acupuncture.  Radiographs of the right wrist that occurred 2016 did identify a possible occult fracture of the distal radius.  An MRI of the right wrist that occurred in 2019 identified no evidence of a lunate abnormality. However, there were findings suggestive of de Quervain's tenosynovitis and a tear in the volar fibers of the scapholunate ligament.  The patient underwent an MRI of the left wrist in 2018 that did not identify Keinbock's disease. However, they did identify a subcortical cyst in the volar distal scaphoid.  The patient had on-going pain and functional limitations related to the injury.  A prescription was written in 2018 for an exogen,  bone growth stimulator.  An ongoing recommendation was made for several months that a bone growth stimulator would benefit the patient.  Treatment was initiated in 2018 resulting in 80 percent functional recovery of the wrists. This treatment plan was reviewed and received an adverse determination due to a lack of clinical documentation to support the need for use of this type of equipment.  

The patient was evaluated in 2018, by a hand surgeon, who stated that the both the MRI of the right hand and radiographs were difficult to read due to questionable quality. According to a clinical note, the orthopedic surgeon, who is a board-certified specialist for hands and upper extremities, reviewed an MRI of the right wrist and identified findings of Kienbock's which was not included the original report. The patient's clinical presentation was consistent with this as the patient had tenderness over the CMC joint, and dorsal and volar aspect of the wrist that increased range of motion activities.  The physician also noted that this type of injury is not always immediately evident, and the patient was advised to wear braces and a bone growth stimulator was ordered. The patient had seen multiple specialists and orthopedic surgeons regarding her persistent and worsening wrist symptoms.  Kienbock's Disease can be a difficult diagnosis to confirm, but this patient has very classic symptoms.  

This patient is an older woman, a former smoker and is being treated with a synthetic thyroid hormone.  In consideration of her current level of physical health and potential complications that could develop based on her medical history, surgery would not be the best option for this patient as initial treatment. Use of a bone growth stimulator is consistent with the standard of care.