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

Diagnosis: Weakness and Dizziness
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

The patient is an adult female with diabetes and hypertension. She presented to the hospital with numbness and weakness to feet, along with generalized weakness and edema. The patient 
was taking non-steroidal anti-inflammatory drugs (NSAIDs) prior to admission and was noted with nephrotic syndrome. She was seen by nephrology services. During the stay, the patient was hemodynamically stable. She was tolerating oral intake, and she 
was with stable cardiac function. The patient was started on an angiotensin II receptor blocker (ARB) for nephrotic syndrome with outpatient follow-up with renal services on discharge.

The Inpatient Admission was not medically necessary.

The inpatient admission was not the least intensive and/or most appropriate alternatives among diagnostic and treatment options, and the treatment was not provided in the most effective setting. The same treatment could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

Acute cholecystitis and biliary complaints are common inpatient diagnoses. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions [1]. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay [2, 4, 5]. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting [3]. In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase (ALP) and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible [5, 8]. A 50% (percent) increase in the liver function tests can be labelled as mild elevation and is considered negligible by many [9]. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes [6].

Per clinical documentation, this patient presented to the emergency department with epigastric abdominal pain. Vital signs in the emergency department (ED) were within normal limits. The patient was afebrile. Abdominal ultrasound demonstrated findings indeterminate for acute cholecystitis. White blood cell count was elevated to 14.1. Liver function tests were normal initially. The total bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) increased the following day to 1.2, 240, and 145, respectively. The patient underwent a laparoscopic cholecystectomy with cholangiogram. There were no reported complications. There is no further clinical documentation of a need for inpatient admission. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation [7]. Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in this circumstance. Per provided clinical documentation, inpatient admission was not medically necessary. Observation status would be more appropriate. The health plan acted reasonably.

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

Diagnosis: Dysuria
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female with a history of anxiety, asthma, and recurrent urinary tract infections. She presented to urgent care with complaint of dysuria. The patient had a computed tomography (CT) scan obtained that showed no stones or hydronephrosis and was discharged to home on Bactrim. The patient took one dose that night. On the next day, the patient had severe left-sided suprapubic pain radiating to her flank, urinary frequency, and dysuria and thus presented to the emergency department.

An ultrasound demonstrated no hydronephrosis or hydroureter, no stones, and no obstruction. The patient expressed anxiety regarding concerning history of bacteria in her blood and dislike of taking medications, including anxiety medications. On presentation, she was afebrile, with temperature of 98 degrees, respiratory rate of 20, blood pressure 140/94 and oxygen saturation 99% (percent). She was visibly uncomfortable. She received a fluid bolus, intravenous cetriaxone, morphine, and ketorolac.

The patient's urinalysis showed over 100 red blood cells, 0-5 white blood cells, and few squamous cells. On the day before, urinalysis showed over 100 red blood cells, 11-20 white blood cells, and moderate bacteria. The patient's creatinine was normal and white blood cell count was not elevated. She was admitted for management of pain and pyelonephritis.

Throughout the course of her admission, the patient remained afebrile, with normal respiratory rate and oxygen saturation. Blood pressure ranged from 130-140/64-94. Infectious disease was consulted on day # (number) 4, at which time the patient was noted to be feeling better. Her back pain improved from 10/10 to 3-4/10 and frequency of urination improved. Her urine culture was noted to be with no growth. Infectious disease recommended continued treatment with oral cefdinir for seven days. The patient was noted to have poor oral intake and nausea on day of admission. On day #4 she complained of nausea. The patient was discharged to home with recommendation for outpatient urology evaluation on the following day.

The inpatient hospital admission was not medically necessary.

The patient could have been managed at a lower level of care. The patient was hemodynamically stable and white blood cell count was not elevated. She had no co-existing medical problems that necessitated acute inpatient admission. She had normal renal function and no hydronephrosis or stones on CT and ultrasound.

This patient was hemodynamically stable and had normal renal function. Her kidney function testing and white blood cell count were not elevated. She was anxious about going home and fearful, but her laboratory and radiologic evaluation and vital signs did not support acute inpatient care. She had no renal anomalies, no stones, and no significant comorbidities. She was afebrile and hemodynamically stable.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decline in functional and emotional status
Treatment: Increase Social Day Care Services for a Total Amount of 3 Days Per Week
The insurer denied: Increase Social Day Care Services for a Total Amount of 3 Days Per Week
The denial is overturned.

The patient is an elderly male. His conditions include osteoarthritis. He lives alone. Denial of increase social day care services for a total amount of three days per week is being appealed. The health plan approved a total of two days per week. The patient's Uniform Assessment System evaluation completed 4 months ago shows modified independent cognition and he needs assistance with all activities of daily living (ADLs), except independent with bed mobility and eating. Compared to Uniform Assessment System evaluation completed 5 months ago, there has been a decline with all activities of daily living.
An appeal statement notes the patient cannot go outside without assistance. He feels lonely, depressed, and anxious since his wife passed 6 months ago. He would like to socialize.

The Increase Social Day Care Services for a Total Amount of 3 Days Per Week is medically necessary. 

Adult day care centers may focus primarily on social interaction, provide medical care, or be dedicated to dementia care. Adult day care can provide social interaction. They provide a variety of services and activities, including social activities. Social Adult Day Care usually do not need medical attention during the day but may need supervision for safety and activities of daily living.
This patient lives alone. There has been decline in functional and emotional status since the death of his wife 6 months ago. The appeal statement notes the patient has been depressed since 
that time and needs socialization. The Uniform Assessment System evaluation shows decline in the functional status that can be attributed to depression. Based on the patient's clinical status, 
the requested increase social day care from two to three days a week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe dental anxiety. 
Treatment: intravenous moderate (conscious) sedation/analgesia (D9239 and D9243). 
The insurer denied coverage for intravenous moderate (conscious) sedation/analgesia. 
The denial is overturned. 
 
Based on the submitted clinical documentation including narrative letter and clinical notes, it appears this child with severe dental anxiety presented for dental treatment requiring an extraction of a tooth. Due to anxiety contributing to poor compliance in the outpatient setting, it was recommended that all dental treatment be performed under deep sedation by oral surgery. The insurer has denied services as not being necessary as the situation does not meet their stipulated criteria. 

Upon review of the documentation submitted and as enumerated above, this patient had dental needs that would be difficult to provide in the outpatient setting due to the age of the patient and poor compliance/anxiety. Therefore, it was recommended that treatment be performed in a controlled setting under deep sedation/general anesthesia. This provides the benefit of completing dental needs and anesthesia assures patient compliance. This is a standard of care treatment for this clinical situation when dealing with pediatric patients. This treatment is supported in the literature (see below). Further, the treatment plan as recommended fulfills and meets all of the insurer's medical necessity criteria. As such the services recommended are considered medically necessary. 

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 intravenous moderate (conscious) sedation/analgesia - first 15 minutes (D9239) and Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minutes increment (D9243) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
Patient is a young adult male with a history of Asthma and Marijuana use. He presented to the emergency department (ED) with complaints of (C/O) shortness of breath (SOB) and Wheezing. Patient had run out of inhalers at home. Patient has prior history of Intubation.

At presentation to the ED, Temperature 97.2 degrees F (Fahrenheit), Respirations 18, Blood Pressure 116/72, pulse 107.  Oxygen saturation was 96% (percent) on room air.

Patient was treated with Steroids, Nebulizers, Magnesium, and Tylenol. Patient initially improved but deteriorated and developed respiratory distress with use of accessory muscles.
Patient was given Epinephrine twice. His venous blood gas (VBG) was 7.31,49 and 38.
Patient was placed on bilevel positive airway pressure (BIPAP) for respiratory distress. Decision was made to admit him to the intensive care unit (ICU). The patient was not tolerating BIPAP, so had to be switched to high flow nasal canula (HFNC). He was given Ketamine for agitation and then placed on Ketamine intravenous (IV)drip. White blood cell count was 13.3. Chest X-ray showed no acute infiltrates. Repeat VBG 7.41/38/28.

Based on worsening respiratory status it was appropriate to admit him to ICU. He had respiratory acidosis and worsening hypercapnia. Patient remained stable in ICU under close monitoring. By the next day he was transferred to medical floor. Ongoing treatment was continued.

Pt decided to sign out against medical advice (AMA). He did not wish to remain in the hospital as he had air tickets to travel out of the country.

This patient was in a critical condition with Status Asthmaticus and needed ICU admission and treatment with Ketamine drip. Admission was appropriate. This patient was not stable to be treated in any other setting.

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

Diagnosis: Cancer. 
Treatment: Stem cell transplant. 
The insurer denied a stem cell transplant. 
The health plan's determination is overturned. 

The patient is a woman with a history of an old myocardial infarction (MI) > 20 years ago without evidence by echocardiogram (ECHO) and electrocardiogram (ECG) and details unknown. The patient has a long history of smoking and carries a diagnosis of chronic obstructive pulmonary disease (COPD). She presented with back pain and was diagnosed with multiple myeloma with reportedly unfavorable cytogenetics. She was treated with D-RVD (Daratumumab + Revlimid + Velcade + dexamethasone) and achieved an unclear response and the plan was to proceed with a autologous hematopoietic stem cell transplantation (HSCT). 

The stem cell transplant is medically necessary for this patient. The use of a stem cell transplant in this patient is the standard of care as evidenced by the National Comprehensive Cancer Network (NCCN) guidelines. Her pulmonary and cardiac function meet the standard guidelines for patient eligibility. Although the transplant is not curative it does improve the quality of life (QOL) and extend disease-free survival (DFS). More than 30 years after its introduction, autologous stem cell transplantation (ASCT) remains the standard of care for young patients with newly diagnosed multiple myeloma. Not only did the arrival of novel agents such as immunomodulatory drugs (IMiDs), proteasome inhibitors (PI) and monoclonal antibodies not replace ASCT, instead they solidified its central role as standard of care. "
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Daytime sleepiness. 
Treatment: Sleep study. 
The insurer denied a sleep study. 
The health plan's determination is upheld. 

This is the case of a female patient who suffers from daytime sleepiness. The patient had multiple sleep studies in the past that were all within normal limits. The provider is requesting the coverage of another sleep study. 

Sleep study is not medically necessary for this patient. 
Narcolepsy is a serious, life-long, potentially disabling disorder. Symptoms are usually first noticed during the early teenage years. There is no known cure for narcolepsy and no completely adequate treatment is available. 
Narcolepsy is a chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. At various times throughout the day, people with narcolepsy experiences fleeting urges to sleep. If the urge becomes overwhelming, individuals will fall asleep for periods lasting from a few seconds to several minutes. In addition to excessive daytime sleepiness (EDS), three other major symptoms frequently characterize narcolepsy: cataplexy or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or upon awakening; and brief episodes of total paralysis at the beginning or end of sleep. 
The Multiple Sleep Latency Test (MSLT) is performed to evaluate the presence of pathological sleepiness and to confirm the diagnosis of Narcolepsy. These individuals are studied during 5 daytime naps taken 2 hours apart. The mean MSLT score is usually less than 8 minutes. Narcolepsy is excluded by the absence of sleep-onset rapid eye movement (REM) (SOREM) periods on the 5-nap MSLT. 
According to the American Academy of Sleep Medicine (AASM) an in lab sleep study followed by MSLT is indicated as part of the "initial" evaluation of patients with suspected narcolepsy to confirm the diagnosis. 
The review of this patient's record revealed that the patient was referred to the sleep lab for evaluation of daytime sleepiness. There is no evidence that the patient had specific symptoms of Narcolepsy such as sleep paralysis, cataplexy and/or hypnagogic hallucination. Most importantly, the patient had 3 sleep studies followed by 3 MSLT in the past 8 years and were all negative for narcolepsy. There was no significant change in the patient's medical condition to warrant another sleep study and another MSLT.
Therefore, the requested sleep study is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased oral intake
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a young male who presented with diarrhea, vomiting, and decreased oral intake. He was well until 10 days prior to presentation when he developed a cough, runny nose, and congestion. He later also developed vomiting and diarrhea. On the day prior to presentation, he had 4 episodes of diarrhea and decreased oral intake. He only had 1 wet diaper over 24 hours. He became ill appearing, weak, and sleepy and was therefore brought to the emergency department for evaluation.

Inpatient hospital stay was medically necessary for this patient. He required intravenous fluids and dextrose to treat dehydration, hypoglycemia, and lethargy, along with close monitoring.
This is a young boy with a complex medical history who presented with dehydration, acidosis, and hypoglycemia. He continued to have hypoglycemia despite getting dextrose in the emergency department. He was initially described as ill-appearing and lethargic with dry mucosa. He required hospital admission for continuation of treatment with intravenous fluids with dextrose, and close monitoring of both his clinical status and laboratory values with additional treatments as needed.
The decision making at the time of admission for this patient was consistent with his young age, the presence of a complex medical history, his presentation with ill appearance, acidosis, and hypoglycemia that persisted despite oral dextrose, and the need for prompt initiation of treatment along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Respiratory distress
Inpatient Hospital

Diagnosis: Respiratory distress, seizures
Inpatient Hospital Stay
The insurer denied an Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the hospital for a cough, fever and seizures. He had an episode of unresponsiveness and apnea so Emergency Medical Services (EMS) were called to his house. He received DuoNeb therapy by EMS and was transferred to the emergency room. His venous blood gas showed acidosis with potential hydrogen (pH) of 7.2 and elevated lactate. He received intravenous fluid bolus and racemic epinephrine. He was also started on intravenous antibiotics. He was started on supplemental oxygen via high flow nasal cannula due to increased work of breathing. He gradually improved and was discharged home in a stable condition. At issue is the medical necessity of an inpatient level of care.

The admission was medically necessary. This patient presented to the hospital via emergency medical services (EMS) for a new onset seizure and respiratory distress. On presentation, he was found to have respiratory acidosis with a potential hydrogen (pH) of 7.2 and elevated lactate. He received intravenous fluid bolus and racemic epinephrine. He was also started on intravenous antibiotics. He was started on supplemental oxygen via high flow nasal cannula due to increased work of breathing.
According to Orloff, Kirsten E et al: "Pediatric acute respiratory distress syndrome (PARDS) is a significant cause of morbidity and mortality in children. Children with PARDS often require intensive care admission and mechanical ventilation".
The member's condition was severe and required extensive medical interventions and close monitoring. The member's condition could not have been managed safely or effectively at a lower level of care.
Therefore, the hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis (of right lower limb)
Treatment: Skilled Nursing Facility Level II
The insurer denied: Skilled Nursing Facility Level II
The denial is upheld.

The patient is an adult male who was admitted to skilled nursing facility from the hospital. The patient was treated for cellulitis of the right lower limb at the hospital and had undergone incision and drainage of the right lower extremity necrotic soft tissue at the hospital. The patient had past history of encephalopathy, substance abuse, hepatitis C virus (HCV) - status post treatment, right third finger osteomyelitis - treated with antibiotics. On admission to the skilled nursing facility, the patient was afebrile and had stable vital signs. The patient was alert, oriented and responsive to all stimuli. His right lower leg had a wound dressing and Unna boot. The patient was able to stand on his unaffected leg with assistance and required one person assistance for transfer. The patient was able to perform bed mobility independently. The patient was able to ambulate ten feet with rolling walker and one person. The patient was admitted for wound care and physical therapy / occupational therapy / rehab services. The patient benefited from above services, continued to improve and was discharged.

The proposed skilled nursing facility level II was not medically necessary.

The patient had improved steadily after admission to nursing home and by the requested dates of service, the 
patient had improved notably and did not require continued admission for the above services. The patient had gained adequate strength and had progressed from a physical therapy -
occupational therapy standpoint. The wound was improving and stable without need for additional interventions related to wound care / physical therapy / occupational therapy. In view of above improvements, services provided did not require continued nursing facility stay. The patient could have been managed at a lower level of care for the above period.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly visits
The insurer denied Braces and Monthly visits.
The determination is overturned.

This is a female patient with a buccal (reverse) crossbite on teeth 5 and 12. She presents with a skeletal Class II malocclusion with severe maxillary and mandibular crowding. She has a 4-millimeter (mm) overjet and 7 mm overbite. There is damage to the mandibular incisors. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

Since teeth 5 and 12 are in buccal crossbite, they have no antagonist. As a result, it is extremely likely that these teeth will overerupt. Once this overeruption occurs, it is very difficult to treat. (1) Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance. (2)
In addition to the damage that the patient's buccal crossbite can cause, her deep bite is causing wear to the mandibular incisors (3) which is significant given the patient's age. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For these reasons, treatment is medically necessary.