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

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The health plan denied the inpatient admission.
The health plan's determination is upheld. 

The patient is a with medical history of recurrent acute pancreatitis previously complicated by pseudocyst. He presented to the emergency department with epigastric pain radiating to his back since the prior night. Extensive work-up had been negative, but recent ultrasound had shown two non-obstructing biliary calculi. Vital signs were unremarkable. Physical examination was notable for no specific point abdominal tenderness. Labs showed elevated white blood cell count of 12.0, normal hemoglobin but an elevated hematocrit of 50.4%, elevated bilirubin of 1.5, and elevated lipase of 2,635. Computed tomography scan of the abdomen and pelvis showed acute interstitial pancreatitis. 

The inpatient hospital admission is not medically necessary. In this case, the patient with history of recurrent acute pancreatitis presented with abdominal pain consistent with acute pancreatitis, elevated lipase higher than three times the upper limit of normal, and imaging consistent with pancreatitis. His pancreatitis was uncomplicated, and there were no complications such as pancreatic necrosis, pseudocyst, or abscess. No procedural interventions such as endoscopic ultrasound were necessary. He was appropriately treated with nil per os status and intravenous fluids, and his symptoms improved; his diet was advanced and discharge was then deemed appropriate. The treatment provided (including observation, labs, intravenous fluids, Gastroenterology consultation, and imaging), could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The health plan denied the inpatient admission.
The health plan's determination is upheld. 

The patient is a with medical history of recurrent acute pancreatitis previously complicated by pseudocyst. He presented to the emergency department with epigastric pain radiating to his back since the prior night. Extensive work-up had been negative, but recent ultrasound had shown two non-obstructing biliary calculi. Vital signs were unremarkable. Physical examination was notable for no specific point abdominal tenderness. Labs showed elevated white blood cell count of 12.0, normal hemoglobin but an elevated hematocrit of 50.4%, elevated bilirubin of 1.5L, and elevated lipase of 2,635. Computed tomography scan of the abdomen and pelvis showed acute interstitial pancreatitis. 

The inpatient hospital admission is not medically necessary. In this case, the patient with history of recurrent acute pancreatitis presented with abdominal pain consistent with acute pancreatitis, elevated lipase higher than three times the upper limit of normal, and imaging consistent with pancreatitis. His pancreatitis was uncomplicated, and there were no complications such as pancreatic necrosis, pseudocyst, or abscess. No procedural interventions such as endoscopic ultrasound were necessary. He was appropriately treated with nil per os status and intravenous fluids, and his symptoms improved; his diet was advanced and discharge was then deemed appropriate. The treatment provided (including observation, labs, intravenous fluids, Gastroenterology consultation, and imaging), could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital with a history of progressively worsening abdominal pain. Evaluation included a physical exam, labs, and a computed tomography (CT) scan. He was without a fever at the time of presentation. His vital signs were normal in the emergency department (ED). Lab data identified a white blood cell count (WBC) of 12.2 thousand (K). A computed tomography (CT) scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics.
A surgery consultation was obtained. He was started on intravenous (IV) antibiotics with the plan to trend the white blood cell count (WBC).
The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. A drain was placed at the time of surgery. He was provided intravenous (IV) fluid and perioperative antibiotics. His vital signs remained normal throughout the hospitalization without a fever. His diet was advanced and pain management was converted to oral medications. He was discharged home.
At issue is the medical necessity of an inpatient admission.
Inpatient care was not medically necessary. The care and treatment provided could have appropriately rendered with a lower level of care.
This previously healthy patient presented to the ED with abdominal pain. The evaluation with examination, lab data, and a CT scan established the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and IV antibiotics. The early post-surgical course was uncomplicated. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for pre-surgical assessment, surgical consultation, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.
 Generally accepted criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed without inpatient admission. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for pre-surgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis of left hand, open wound of left hand
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The determination is upheld.

This case involves a man with no medical history who presented to the hospital with a left-hand infection, which started one day before this presentation. He injured his left hand while at a construction site, sustaining a laceration. He was admitted the previous day and started on intravenous (IV) antibiotics but left against medical advice (AMA). He subsequently returned to the hospital for reevaluation. He denied any fevers or chills. The patient has a history of IV heroin abuse, reportedly. The temperature was 98.3 degrees Fahrenheit, the heart rate was 81 beats per minute (bpm), and his blood pressure was 150/75 millimeters of mercury (mmHg). On examination, he had an open draining wound to the left first digit around the metacarpophalangeal joint (MCP) with surrounding erythema and edema. There was no crepitus or streaking to the upper extremity.

Electrolytes and renal function appeared stable. The white blood cell count was mildly elevated to 12. He was readmitted to the hospital under medicine service and started on IV Vancomycin and Zosyn. Plastic surgery assessed the patient and recommended soaking the wound and Betadine, elevation of the arm, and obtaining a computed tomography (CT) scan. The CT scan showed no evidence of abscess or bony erosion. The medical team also requested an infectious disease consultation. Given the heroin history, they placed him on Methadone.

By the following morning, the patient was becoming agitated, pacing in and out of the room, asking to go downstairs to smoke, as well as Methadone and Valium. He again decided to leave AMA. He was prescribed Augmentin and Doxycycline.

At issue is the medical necessity for the inpatient hospital admission.

I uphold the health plan's determination of medical necessity, in full.

No, an inpatient hospitalization was not warranted in this case. 

Based on the provided documentation, an alternate level of care was indicated. The patient had cellulitis of the finger without evidence of abscess, necrotizing fasciitis, or osteomyelitis on imaging. He did not appear septic, did not require surgical debridement, and there was no streaking up the arm to suggest lymphangitis. There was an adequate response to antibiotic therapy. There is no clinical documentation to suggest a failure of appropriate outpatient antibiotic therapy to warrant an inpatient hospital admission.

Inpatient hospital admission is not indicated. This patient's condition could have been managed under an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient had an apparent seizure. He was riding in the back seat of a car when he was noted by his mother to have the sudden onset of staring and unresponsiveness. This was followed by generalized shivering with a duration of about 25 seconds. Postictally, he was lethargic and poorly interactive. He was taken to the emergency room, where he was still slightly lethargic at the time of arrival but regained a fully normal level of consciousness after several minutes. In the emergency room, his vital signs were normal. He received an intravenous bolus of saline. Laboratory tests, including a complete blood count (CBC), basic metabolic panel, urine drug screen, and head computed tomography (CT) scan were all normal or negative. He was admitted to the hospital, where he underwent a routine electroencephalogram (EEG) and a continuous video EEG, both of which were normal. He remained healthy throughout the hospital stay and had no further seizures. He was discharged to home. At issue is the medical necessity of an inpatient stay. 

It was not medically necessary for the patient to be admitted at the acute inpatient level of care. He could have been treated at a lower level of care. 

When a previously healthy young child has a single seizure, it is customary and appropriate for that child to be evaluated in the emergency room and to undergo laboratory testing, in order to assure that the child does not have a serious and potentially life-threatening metabolic, infectious, oncologic, hematologic, or other disorder. If the child regains a normal level of consciousness and has normal vital signs, and if the laboratory testing is reassuring, then that child can safely and appropriately be treated at a lower level of care. An EEG can be obtained as an outpatient. It is not customary, appropriate, or necessary to admit the child at the acute level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD). 
Treatment: Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week - Total of 168 Hours per Week (Split Shift). 
The insurer denied Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week - Total of 168 Hours per Week (Split Shift). 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypothyroidism, obstructive sleep apnea, coronary artery disease, congestive heart failure (CHF), hyperlipidemia, hearing loss, chronic obstructive pulmonary disease (COPD), oxygen dependence, bipolar, morbid obesity, urinary incontinence, bowel incontinence, diabetes mellitus type 2, gout, and history of breast cancer who had been assigned PCS (personal care services). 

Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week - Total of 168 Hours per Week (Split Shift) are medically necessary for this patient. 
There is documentation of worsening physical functioning following hospitalization and subsequent rehabilitation stay. The patient has a continuous positive airway pressure (CPAP) device for chronic respiratory failure and the patient is unable to apply, remove, or adjust this device. The patient's home does not accommodate for a space for a PCS to sleep. The patient requires maximum assistance with transfer toilet and toilet use, therefore the patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's medical provider also documented the patient's toileting care needs at least every 2-4 hours in the overnight hours which would not allow a PCS the required 5 hours of uninterrupted sleep in the overnight hours. The requested increase in PCS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment or medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS services 24 hours/day, 7 days/week, split-shift, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic neck and back pain.
Treatment:  Personal Care Worker Service-via CDPAS (Consumer Directed Personal Assistance Service) hours- 7 hours x 7 days a week, total 49 hours per week.

The insurer denied Personal Care Worker Service-via CDPAS hours- 7 hours x 7 days a week, total 49 hours per week.  The determination is overturned.

The patient is a male with a past medical history (PMH) of left eye blindness, glaucoma of both eyes, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (T2DM), coronary artery disease (CAD), chronic back pain and chronic neck pain. His primary care doctor recommended consumer directed personal assistance services increase to 49 hours per week instead of 35 hours per week. At issue is the medical necessity of the requested health service/treatment of Personal Care Worker Service via Consumer Directed Personal Assistance Services (CDPAS) hours- 7 hours x 7 days a week, total 49 hours per week.

The health plan, in its determination of medical necessity, acted reasonably. However, the health plan did not act in the best interest of the patient. This is a severely visually impaired patient who suffers from rheumatoid arthritis. The patient is heavily dependent on dressing himself, bathing, going to the bathroom and using the toilet. Patients with rheumatoid arthritis are at a higher risk of fracture than the typical population and require closer monitoring. This patient has had a fall in the past 12 months. In addition, the patient has 10 minutes to eat per meal. It is not reasonable to expect this patient to eat a meal in 10 minutes. He should also be ambulatory for more than 20 minutes per day. Given his history of diabetes, he should be walking 20-30 minutes per day with assistance. While the patient gets help from family and friends for activities of daily living, it is not reasonable to have this burden placed on them, especially when they have no training in specifically caring for patients like this.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient is an adult female who came to the emergency room (ER) with hemoglobin (Hgb) 6.9. At the primary doctor's office (PMD) office the Hgb level was 6.3 and mean corpuscular volume (MCV) 73.7. She was intermittently tachycardic. One unit of packed red blood cells (PRBC) was transfused. The patient was monitored and Hgb level improved after treatment. She denied heavy vaginal or rectal bleeding, chest pain (CP), shortness of breath (SOB) or palpitations.

This patient was not symptomatic, had essentially normal vitals, MCV that suggested iron deficiency, and no signs or complaints of bleeding. She could have received the transfusion in the ER, or completed iron studies, if necessary, on the observation level or at home, and been started on oral iron and discharged.      

"Anemia is among the most common medical problems and clinical and laboratory evaluation need to be approached logically. The complete blood count with red cell indices offers clues to diagnosis. Many anemias have characteristic red cell morphology. The reticulocyte count serves as a useful screen for hemolysis or blood loss. Testing for specific causes of the anemia is performed". (Cascio, M. J., & DeLoughery, T. G. 2017)

"Patients with anemia are frequently encountered in the emergency department (ED); emergency physicians (EPs) often play an important role in the evaluation and management of anemia. Although many patients have findings consistent with anemia on routine laboratory tests, only a small percentage will require acute intervention". (Vieth, J.T. & Lane, D.R.., 2017)

"Iron deficiency (ID) and iron deficiency anemia (IDA) are highly prevalent among women across their reproductive age. An iron-deficient state has been associated with and causes a number of adverse health consequences, affecting all aspects of the physical and emotional well-being of women. Heavy menstrual bleeding, pregnancy, and the postpartum period are the major causes of ID and IDA. However, despite the high prevalence and the impact on quality of life, ID and IDA among women in their reproductive age is still underdiagnosed and undertreated". (Cappellini, M.D., et al., 2022)                                                        

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male with a history of hypertension, coronary artery disease (CAD) with recent ST-Elevation Myocardial Infarction (STEMI) status/post (s/p) left anterior descending (LAD) stent who was brought to the emergency department (ED) by Emergency Medical Services (EMS) after a syncopal event at home. The patient reportedly had been drinking alcohol and using marijuana around the time of the event. In the ED, the patient was hypertensive. An electrocardiogram (ECG) demonstrated anterior ST elevation. Notable labs showed acute on chronic renal failure and elevated cardiac troponin. The patient was admitted to telemetry service under inpatient level of care for further evaluation and management of syncope. The patient was found to be orthostatic by vital signs and was hydrated with intravenous fluids (IVF). 

The inpatient level of care was medically necessary, and in the best interest for the safety of this patient given the patient's concerning presentation for syncope was likely cardiac related. Because the patient had recently experienced an anterior ST-Elevation Myocardial Infarction (STEMI) due to acute left anterior descending (LAD) occlusion requiring stent placement resulting in an ischemic cardiomyopathy coupled with lack of prodromal symptoms, a cardiac etiology of syncope was likely in this case. Inpatient monitoring on telemetry service for evidence of potentially life-threatening tachyarrhythmias including ventricular tachycardia (VT) / ventricular fibrillation (VF) and bradyarrhythmias was medically necessary with electrophysiologic (EP) consult and placement of LifeVEST for sudden cardiac death protection. Furthermore, evaluation and management of this patient's syncopal event under a lower level of care would have been medically inappropriate and unsafe in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Acute Myeloid Leukemia
Treatment: Posaconazole DR
The insurer denied Posaconazole DR
The determination is overturned.


This is a male patient with acute myeloid leukemia. He is currently receiving standard induction therapy with arsenic trioxide+ATRA [all-trans retinoic acid]. He is on acyclovir. He also has an active osteomyelitis of the right foot for which he is receiving antibiotic therapy. Posaconazole has been recommended for antifungal prophylaxis and is under review.

The use of primary prophylaxis in this case is consistent with the literature and national guidelines. In patients such as this, the authors of UpToDate state "...For selected patients who are expected to experience prolonged severe neutropenia (absolute neutrophil count [ANC] less than (<) 500 cells/microliter for greater than [>]7 days) due to intensive chemotherapy for acute myelogenous leukemia (AML)..., we suggest prophylaxis against invasive mold infections and Candida spp [Candida species] with posaconazole...rather than targeted anti-Candida prophylaxis with fluconazole...". Itraconazole is not known to be as effective as posaconazole. These recommendations are generally in keeping with the 2018 American Society of Clinical Oncology and Infectious Diseases Society of America (IDSA) antimicrobial prophylaxis guidelines for patients with cancer-related immunosuppression and the 2016 IDSA guidelines for the diagnosis and management of aspergillosis. This is similarly a category 1 recommendation from the National Comprehensive Cancer Network (NCCN). For these reasons, the formulary drug would generally be considered inferior to the non-formulary alternative.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Stroke.

Treatment: Skilled Nursing Facility.

The insurer denied coverage for continuing skilled nursing facility admission.

The denial is modified.

 
This is an adult with chronic medical problems including diabetes, stroke and substance abuse. He was initially admitted to the Skilled Nursing Facility (SNF). During his stay he developed hypoglycemia and sepsis that required transfer to an acute care hospital.  He was readmitted to the SNF. Under review is the medical necessity for continued stay at the SNF.

The patient was initially appropriate for the SNF level of care during the first and part of the second SNF admission. (1, 2, 3) His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. However, the treatment notes after the second admission document only modest improvement. The patient improved to the supervision level for bed and wheelchair mobility. He required only set-up for transfers and able to ambulate household distances with a rolling walker (100 feet). Performing activities of daily tasks such as hygiene and dressing was at the contact guard assist level. By this time, the patient's diet was mechanical soft with thin liquids. Subsequent improvement could have been attained at a lower level of care such as long-term care, home care with visiting therapy services or as an outpatient. In addition, there were no specific acute medical or complicated nursing issues that required continued stay at the SNF, again could have been provided via long term care or home with visiting nursing services.  

Based on the above, the insurer's denial must be modified. 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 continued stay in Skilled Nursing Facility should be modified. 

Medical necessity for continued stay at the SNF is partially substantiated. SNF from the readmission up to 12 days is medically necessary.