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

Diagnosis: Weakness and Dizziness (diabetes)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a transgender female with history of alcohol abuse. She presented with blurred vision, dizziness, nausea, and vomiting.

The patient was diagnosed with a new diagnosis of diabetes. Her vital signs were as follows: Temperature 97.5, heart rate 114, respiratory rate 18, BP (blood pressure) 152/102, O2 (oxygen) saturation 96%. She was alert and oriented on exam.

The patient's glucose was 730 mg/dL (milligrams per deciliter), bicarbonate 22, and serum osmolarity 295. She was treated with intravenous insulin and fluids. She was transitioned to subcutaneous insulin. Cardiology was consulted for abnormal EKG (electrocardiogram).

The patient left against medical advice. The inpatient stay is under review.

No, the Inpatient admission was not medically necessary.
This patient presented with new onset diabetes mellitus with dehydration. Her dehydration and tachycardia quickly resolved with intravenous hydration. Her hyperglycemia improved with insulin therapy. She did not have acidosis to support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperosmolar hyperglycemic syndrome. She was hemodynamically stable. She did not have acute renal failure, acute coronary syndrome, evidence of infection, or other acute medical illness that required hospitalization. Therefore, no, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The requested inpatient stay was not medically necessary and was appropriately denied by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I skeletal relationship, moderate maxillary spacing, deep bite, missing
maxillary first premolar and mandibular right second premolar

Treatment: D8080 Braces and D8670 Monthly Visit (x12), Pre-service

The insurer denied the D8080 Braces and D8670 Monthly Visit (x12), Pre-service.

The denial is upheld.

The patient is a female. The request is for dental services for orthodontic treatment (braces) and monthly visits, pre-service.  Per the provider's clinical summary - the patient presents with a  class I skeletal relationship, moderate maxillary spacing, deep bite, missing maxillary first premolar and mandibular right second premolar, and anterior crossbite with gingival attachment loss (mandibular right canine).

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labiolingual Deviation Index (HLD) Index Report, the score needed for approval for orthodontic treatment.  The provider appealed the claim because of the anterior crossbite (mandibular right canine).

No, the proposed treatment of orthodontics therapy and monthly visits is not medically necessary.
The photos and x-rays submitted do not show or support the existence of an anterior crossbite at the mandibular right canine.

Based on the documentation presented, the crossbite that was stated by the provider in the clinical summary is not substantiated; therefore the proposed treatment of orthodontic therapy is not warranted.

Yes, the health plan acted reasonably with sound medical judgement and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: General debility
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 20 Hours Per Week (The patient was sharing 40 hours/week with spouse, and this was reduced to 24 hours/week shared with spouse)
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS) 20 Hours Per Week (The patient was sharing 40 hours/week with spouse, and this was reduced to 24 hours/week shared with spouse).
The denial is upheld.

The patient is a female. Reduction of Consumer Directed Personal Assistance Services (CDPAS) from 40 hours/week to 24 hours/week as a shared/mutual case with her spouse is being appealed.  The patient was sharing 40 hours/week with spouse.  The patient's daughter requested additional hours because the patient has problems with her knee and needs assistance with ambulation.

UAS (Uniform Assessment System) evaluation completed shows modified independent cognition and functional status: maximal assistance with stairs; extensive assistance with meal preparation, housework, shopping, transportation, bathing, lower body dressing, and walking; limited assistance with managing finances and medications, personal hygiene, upper body dressing, locomotion, and toileting; supervision with bed mobility; and independent with eating.  The patient is continent.  The patient has a shower grab bar, bedside commode, and adult protective underwear.  The patient's daughter is the CDPAS aide.  The patient receives Social Adult Day Care 4 days per week.

No, the requested health service is not medically necessary.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs), health maintenance activities, and routine support services.  Reduction of CDPAS from 40 hours/week to 24 hours/week as a shared/mutual case with the patient's spouse is being appealed.

The patient was sharing 40 hours/week with her spouse.  Assessment shows the patient needs assistance with preparing meals, housekeeping, laundry, shopping, bathing, dressing, personal hygiene, and toileting.  She does not have incontinence.  The patient receives Social Adult Day Care 4 days per week.  The patient's daughter is requesting additional hours because the patient needs assistance with ambulation.  PAS (personal assistance service) is not indicated when no tasks are being performed.  The documentation does not support the proposed CDPAS 20 hours per week.  Based on the patient's functional status and 4 days of adult day care, the approved CDPAS 24 hours per week, shared with her spouse, is appropriate and medically necessary to meet this patient's needs for assistance with ADLs and personal care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pleural Effusion.
Treatment: Extension of an out of network (OON) admission at an inpatient level of care.

The insurer denied coverage for extension of an out of network (OON) admission at an inpatient level of care.
The denial is upheld.

The patient has a history of hypertension, hyperlipidemia, and diabetes mellitus who presented to the hospital with complaints of 2 weeks of shortness of breath (SOB) and 4-day history of worsening cough. The patient also complained of weakness.  
Vital signs were blood pressure 154/92, respiratory rate 18, and heart rate 110.  The patient had a computed tomography (CT) angiogram done which revealed multiple pulmonary nodules which were concerning for metastasis. The patient also had a large left pleural effusion.  The patient was evaluated by multiple specialties - Pulmonary, Cardiology, Gastroenterology (GI) and GYN (gynecology). The patient underwent a thoracentesis in the operating room. Pleural fluid was positive for non-small cell carcinoma.

The patient was seen by Oncology who recommended a PET (positron emission tomography) CT and magnetic resonance imaging (MRI) of the brain for staging. Diagnostic work up to determine the Primary was started. The patient had an esophagogastroduodenoscopy (EGD) done which was unremarkable.

The patient underwent a VATS (video-assisted thoracoscopic surgery) with pleural biopsy (BX). Surgery revealed diffuse disease. A pleurX catheter was placed for drainage of pleural space. The patient was transferred to post anesthesia care unit (PACU) for post operative care.

The patient could have been transferred to an in network facility once VATS BX had been done and the patient had a PleurX catheter in place. It was safe to transfer this patient to an in network facility for ongoing care. The patient was hemodynamically stable and could have been transferred for further management. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for an extension of an out of network (OON) admission at an inpatient level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. She presented with Excedrin use, dark stools, vomiting of dark material, and Hgb (hemoglobin) of 7.1.

The patient was hemodynamically stable. There was no history of cirrhosis. CT (computed tomography) angiogram was negative for active bleeding. She was transfused and started on PPIs (proton pump inhibitors).

The patient's Hgb (hemoglobin) was up to 7.8. EGD (esophagogastroduodenoscopy) revealed multiple gastric ulcers and a duodenal ulcer without active bleeding. Her diet was advanced and she was discharged.

No, the Inpatient admission was not medically necessary.
As the patient was hemodynamically stable, without cirrhosis, without coagulopathy, and as there was no evidence of active GI (gastrointestinal) bleeding, a lower level of care was medically appropriate. When EGD (esophagogastroduodenoscopy) revealed ulcers as the source of her bleeding, and no active bleeding, and as her Hgb (hemoglobin) came up appropriately after transfusion and she remained hemodynamically stable and tolerated a diet, she was medically stable for discharge. Therefore, acute inpatient hospital admission was not medically necessary.

Yes, the medical records and accompanying information are sufficient.
A lower level of care and discharge to outpatient care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia

Treatment: Nexletol 180 milligrams (mg) TAB (tablet)

The insurer denied coverage for Nexletol 180 milligrams (mg) TAB.

The denial is upheld.

The patient has a past medical history notable for hyperlipidemia, asthma, hypertension, recurring bladder infection, hemorrhoids and mild diverticulosis. The patient had in the past tried pravastatin, rosuvastatin, atorvastatin, and simvastatin, all of which resulted in intolerable myalgias and failed other medications to treat his hyperlipidemia and was prescribed a trial of Nexletol. His pre-treatment LDL [low density lipoprotein] was 160 mg/dL (milligrams per deciliter), and his post-treatment LDL was 113 mg/dL. It was noted that he had been off rosuvastatin for 1 month prior to his lab results. 

Bempedoic acid (Nexletol) is not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The attending provider's correspondence indicates that the patient's mother had hyperlipidemia; however, this does not identify the specific diagnosis of familial hyperlipidemia. With regards to the patient, neither the diagnosis of heterozygous familial hyperlipidemia nor that of a personal history of atherosclerotic cardiovascular disease is established. The relevant randomized clinical trials of bempedoic acid indicates this medication is appropriate for patients with a personal history of atherosclerotic cardiovascular disease or the diagnosis of familial hyperlipidemia. As neither of these are present, Nexletol is not medically necessary and is therefore the request for this medication is denied.

Based on the above, the medical necessity for the Nexletol 180 milligrams (mg) TAB is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right inguinal hernia
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This is a male patient who presented with symptomatic right inguinal hernia. This patient was known to have had bilateral fat containing inguinal hernia. The plan was for this patient to have hernia repair after Medical Clearance. This patient eventually had bilateral laparoscopic hernia repair. Subsequently, this patient was discharged on with a Foley catheter for urinary retention.

No, the proposed inpatient admission was not medically necessary.
As per the Milliman Care Guideline (MCG) National Guidelines, the expected length of stay for an inguinal hernia repair is ambulatory.  

As per a review of the summitted medical records and the Letter of Appeal, all the medical care provided to this patient preoperatively and postoperatively including: intravenous (IV) fluids, nothing by mouth (NPO) and later oral diet, oral Flomax, pain medications, blood pressure assessment, and voiding trial with later Foley Catheter, all could have been provided as observation care. This patient who had eventually had a semi-elective laparoscopic hernia repair could have been treated safely, effectively, and efficiently as observation care not needing a full acute inpatient admission.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient to provide safe, effective, and efficient medical care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Croup and Wheezing

Treatment: Inpatient emergency admission

The insurer denied coverage for inpatient emergency admission.

The denial is overturned.

This is a patient with a history of a circumcision 10 days prior to this admission. The cough and runny nose began 3 days prior to the admission and the child was seen by the pediatrician the day prior to admission. There was a sick contact in the home and the pediatrician had prescribed amoxicillin and Tylenol. When the child began to have vomiting and abdominal pain, the mother called emergency medical services (EMS) and the child was brought by ambulance to the emergency room (ER) for evaluation.

In the ER, the mother indicated that the child was not able to keep down liquids and had vomited 5 times. She also indicated that the child was less active and had a decrease in the urine output. On physical exam, he was ill appearing with substernal and subcostal retractions. In the ER, he developed a brassy cough and inspiratory stridor. He was treated with decadron and with a combination bronchodilator (albuterol and atrovent). A chest x-ray demonstrated a patchy area of atelectasis in the lower lobe. He then was treated with racemic epinephrine and his stridor improved, however the stridor recurred after one hour and he was noted to have inspiratory wheezing. A second treatment with bronchodilators and racemic epinephrine was given, but his increased work of breathing and inspiratory wheezing persisted. In view of the ongoing respiratory symptoms, the decision was made to admit the child to the hospital for ongoing treatment with a diagnosis of croup that failed to respond to treatment in the ER. Since pediatric inpatient care was not available at this hospital, the child was transferred to another facility for his hospitalization. When the child arrived, there was evidence of persistent stridor and inspiratory wheezing.

The inpatient hospital admission is considered medically necessary for this patient.

The patient was treated appropriately in the ER for inspiratory wheezing and stridor. The child had been unable to tolerate feedings with 5 episodes of vomiting at home prior to the ER visit. Despite treatment with two doses of racemic epinephrine, the child continued to have inspiratory stridor and wheezing. When he did not respond to treatment in the ER with steroids and racemic epinephrine, a second treatment with racemic epinephrine was required. It was appropriate to have him admitted to the hospital with a diagnosis of croup and wheezing. He was not stable enough to be safely discharged.

The insurer's denial of coverage for the inpatient emergency admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer. 
Treatment: Inpatient admission. 

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

The patient is a female with metastatic breast cancer. She presented initially to the hospital with bowel obstruction due to peritoneal carcinomatosis. She was placed on TPN (Total Parenteral Nutrition), had multiple attempts with IR (interventional radiology) surgery for relief. She was hospitalized and continued to decline and was on hydromorphone for pain control and was placed on PCA (patient-controlled analgesia). She was placed on comfort care. She clinically deteriorated and was placed on 1:1 while on comfort care. Her family eventually agreed to placement, and the patient was discharged to a hospice facility. 

No, the Inpatient admission was not medically necessary. 

This patient was eventually placed on comfort care per the hospital records. Acute care hospitalization is not necessary for comfort care/hospice level care. As such, the Inpatient admission was not medically necessary. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.

The denial is upheld.

The patient is a gentleman that presented to the hospital complaining of palpitations and chest fluttering for a period of two days. Past medical history was relevant for hypertension, obstructive sleep apnea and hyperlipidemia. Upon arrival to the hospital his pulse was irregular and 147 beats per minute (bpm). Blood pressure was stable at 123/98 mmHg (millimeters of mercury), 12 lead electrocardiogram revealed atrial fibrillation with rapid conduction and a ventricular rate of 147 bpm (beats per minute). The patient was treated with intravenous diltiazem and anticoagulant therapy. He was admitted to the hospital and transesophageal echocardiogram with successful direct-current (DC) cardioversion was performed the following day.

This patient presented with symptomatic atrial fibrillation and was effectively treated with atrioventricular nodal blocking agents. Following evaluation and additional testing, the patient underwent DC cardioversion and was released from the hospital. 

Bellew et al studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the ED (emergency department). In this study of almost 600 patients, there was no difference in outcome. American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission. (2) This patient required cardioversion to revert to normal sinus rhythm the day after presentation. In conclusion, this patient could have been managed at a lower level of care.  

The health care plan acted reasonably, with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Posterior teeth.
Treatment:  Root Canal Treatment (D3320) Teeth 12, 13, and 20, Pre-service.
The insurer denied the  Root Canal Treatment (D3320) Teeth 12, 13, and 20, Pre-service.
The denial is upheld.

The patient is a male. The request is for coverage for root canal treatments for teeth #s 12, 13 and 20. The reason for the health plan's denial was that the patient has more than 8 posterior teeth that meet when he touches his teeth together or chews. The reasons for the appeal is that patient wants to treat these teeth rather than extract them.

No, based on the information provided the proposed treatment is not medically necessary.
X-rays are critical to help determine necessity of treatment. The x-rays provided do not diagnose the need for root canal treatments for teeth #'s 12,13 and 20. The x-rays of these teeth, while readable, do not show the tips (that is apex) of all three teeth. If there was an infection of the nerves of these teeth there is a good chance there would be abscesses at the apices of these teeth.  The x-rays provided for review cut off the most important part of the teeth. Without the apices showing on the x-rays, it is impossible to determine if root canal treatments are needed. Therefore, the proposed treatment is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Based on the information provided for review the root canal treatments for teeth #'s 12,13 and 20 cannot be determine as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroid nodule.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned.

The patient is a male with a history of diabetes on metformin and glimepiride. He presented with complaints of swallowing discomfort for one year that increased over the prior 3 months. The patient saw ENT (otolaryngology), who palpated a thyroid nodule. Ultrasound confirmed a left thyroid nodule. Biopsy revealed thyroid cancer. The patient had a BMI (body mass index) of 36. The note reports that the plan was for a total thyroidectomy.

On admission, the patient was noted to have a glucose of 302. The patient had a left hemithyroidectomy and was noted to be tachycardic and hyperglycemic postoperatively. His oral medications were held because of the surgery. He was started on Lantus and sliding scale lispro. The tachycardia was believed to be postoperative pain and volume depletion. He was started on intravenous fluids and treated with pain medications. The patient was admitted for treatment of the hyperglycemia, tachycardia, and pain. The patient continued to have postoperative pain requiring morphine every 3 hours. The patient was unable to tolerate swallowing his meals. Fasting glucose continued to be elevated despite poor PO (oral) intake. The patient was unable to speak with a full voice.

The patient's level of care was changed to inpatient from observation. The patient began tolerating oral intake and had less pain. The patient was safe for discharge.

Yes, the Inpatient admission was medically necessary.

In most patients, thyroidectomy can be a same-day procedure [1, 2, 3, 4]. In certain patients, the hospitalization must be prolonged due to complications for complicating diagnoses. Whenever there are complications preventing the patient from being able to hydrate themselves orally, hospitalization for treating these complications until the patient is able to take PO (oral) intake is necessary.

In this case, the patient had postoperative pain, nausea, tachycardia, hyperglycemia, and the patient was unable to orally hydrate. He required treatment with intravenous fluids and insulin until the patient was able to hydrate himself. The request is consistent with generally accepted standards of medical practice. The inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, as the request was medically necessary as described above.