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

Diagnosis: Sepsis

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

The patient is a female with past medical history significant for gastroesophageal reflux disease, personality disorder, clostridium difficile infection, and multiple urinary tract infections who presented to the emergency department with fever, slurred speech, lethargy, and confusion. Vitals on presentation included the following: Temperature max-106.9 F(Fahrenheit), Blood Pressure-130/60, Pulse 126, Respiratory Rate 24, oxygen (O2) 92% (percent) on Room Air. Laboratory results showed: white blood cell count (WBC) 28.1, hemoglobin (Hgb)-9.5, hematocrit (Hct)-29.4, sodium-126, creatinine-0.7, glucose-204.

Due to the patient's altered mental status, stroke code was called. Head computed tomography (CT) scan was negative.  Patient was started on broad-spectrum antibiotics for sepsis secondary to urinary tract infection and Clostridium difficile infection. Rheumatology was consulted for possible vasculitis and Hematology for persistent leukocytosis and thrombocytosis. Chest x-ray (CXR) revealed right middle lobe discoid atelectasis/scarring. Despite evaluation, "the etiology of fever and leukocytosis remained unclear." CT scan of the abdomen was negative for colitis. The patient remained stable; all cultures were negative. She was discharged to continue outpatient management. 

According to medical records, patient presented with high fevers (106.9 F), tachycardia, and borderline blood pressures. Laboratory results revealed numerous abnormalities including very high leukocytosis (28.1), anemia, high glucose, and low sodium. Additionally, patient had altered mental status. Based on above findings, patient met criteria for sepsis and warranted hospital admission for treatment and further evaluation. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Septic arthritis with multiloculated abscess of the thigh

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a female with history of an anterior cruciate ligament repair to the left leg. She was admitted to the hospital for septic arthritis of the left knee with multiloculated abscess of the thigh, MSSA (methicillin susceptible staphylococcus aureus). She received excision and debridement of the left septic knee joint and the left thigh abscesses. She received intravenous (IV) antibiotics, IV pain control, oral medications, and physical therapy. She was discharged.

The medical record showed the patient had a complicated clinical condition to substantiate all services and length of stay. 

She was found to have a multifocal infection to require several surgical procedures. Her initial operation on admission was not simply an arthroscopic lavage. Her physician performed an arthrotomy in attempt to extensively irrigate and debride the joint. This was unsuccessful to require a return to the operating room for incision and drainage to thigh abscesses. She had a severe problem to support need of hospitalization. The facts were, she had a chronic infection and required continual management to treat her diagnosis. 

Her inflammatory parameters were elevated. She required infectious disease consultation, additional imaging and a peripherally inserted central catheter (PICC) line. She had problems with pain and required parenteral analgesia. 

The services provided could not have been obtained at any other level then full admission.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Left C7 (cervical vertebra 7) radiculopathy.
Treatment:  Cervical Spinal Fusion.
The insurer denied Cervical Spinal Fusion.  
The denial is overturned. 

This is a female patient, with a history of a prior artificial disc replacement at cervical (C)5-6 and has neck and left arm pain. She has had chiropractic therapy and medications without relief. She is a former smoker. The neurologic exam shows no motor weakness. The cervical magnetic resonance imaging (MRI) scan showed a disc protrusion at C6-7 left. The provider has recommended an anterior cervical discectomy and fusion (ACDF) C5-7.

At issue is the medical necessity of Cervical Spinal Fusion.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Cervical Spinal Fusion is medically necessary for this patient.

The procedure is medically necessary. The patient has a left C7 radiculopathy and has a correlating MRI and has failed conservative therapy. The ACDF at C6-7 is supported by the literature and approved by the health plan. Buttermann et al. cite "ACDF leads to significantly improved outcomes for all primary diagnoses and was sustained for greater than (>)10 years' follow-up." In a study looking at cervical fusion and artificial disc placement, Phillips et al. cite "the long-term results show good clinical outcomes after ACDF and PCM arthroplasty." With the cervical fusion at C6-7, this creates a "hybrid" construct C5-7 with an artificial disc at C5-6 and a cervical fusion at C6-7. There is slight kyphosis of the cervical spine looking at a sagittal MRI view.

Therefore, the requested health service/treatment of Cervical Spinal Fusion is medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Multiple sclerosis (MS).
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission. 
The denial is modified.

This case involves a male with a history of primary progressive multiple sclerosis who presented to the hospital for evaluation due to a multiple sclerosis exacerbation causing left-sided weakness. The records indicated that he contracted COVID-19 virus 3 weeks before he was seen in the emergency department. He endorsed progressive weakness and was advised for an extension of inpatient stay. The patient received a notice of adverse determination stating that the inpatient stay was not medically necessary, and that the patient could have had his care rendered at a lower level.  An appeal was submitted stating that the patient initially presented to the emergency department with left-sided weakness and the inability to ambulate. He had a positive stool sample for sugar toxin producing E. (Escherichia) coli and was placed on contact precautions. Additionally, he was still testing positive for COVID-19.  The patient had abnormal vital signs with an elevated temperature and was positive for yeast on his sputum culture. Further findings included elevated liver function testing, with physical therapy assessments noting that the patient continued to require moderate assistance during standing. This review pertains to the denial of coverage for the inpatient stay extension.  

The Milliman Care Guidelines note that clinical indications for admission to inpatient care can include those individuals with multiple sclerosis or other demyelinating diseases who have an exacerbation requiring inpatient treatment.  Symptoms may include acute deterioration requiring inpatient treatment, severe pain requiring acute inpatient management, respiratory insufficiency requiring intubation or inpatient monitoring, inability to manage secretions, or weakness that is progressive or severe and inpatient care is needed due to functional disability and concerns for safety. The patient had initially been documented with a fever of 102.7 and extended care was indicated. However, records noted that the patient was hemodynamically stable and other than having 2/5 left lower extremity strength and 4/5 right lower extremity strength, he had discontinued Solu-Medrol, was on fall precautions, and was off contact precautions with no further episodes of diarrhea in over 48 hours. Given this information, it was determined that the patient could have been safely transferred to a lower level of care to include a skilled nursing facility where he could continue receiving treatment, observation, and assistance given his recent MS flare. He did not require any further extension of inpatient stay.


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

The insurer's denial of coverage for the inpatient stay extension is modified. Medical Necessity is substantiated for the first day of admission, but the denial is upheld for the extended stay.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Personal Care Services, 24 Hours per Day, Split Shift (Two 12-Hour Shifts per Day), 7 Days per Week: Total of 168 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of hyperlipidemia, urinary incontinence, hypertension, anxiety, depression, coronary artery disease, gastroesophageal reflux disease (GERD), insomnia, and osteoarthritis who had PCA (personal care assistant) services based on telephonic assessment performed assessing patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, transportation, equipment management, and bathing. The patient was assessed at limited assistance with tasks of managing medication, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at independent with tasks of bed mobility and eating. 

Personal Care Services, 24 Hours per Day, Split Shift (Two 12-Hour Shifts per Day), 7 Days per Week: Total of 168 Hours per Week are medically necessary for this patient.
Per the patient's medical providers and the patient's daughter, the patient has a decline in cognitive and functional abilities since hospitalization. The patient requires assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient has 24-hour care needs and therefore a task based assessment should not be utilized in determining PCA hours. As the patient has not had a recent assessment since her hospitalization it is assumed that she requires split shift services. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The requested increase in PCA services cannot be met solely with adaptive equipment and 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, Personal Care Services, 24 Hours per Day, Split Shift (Two 12-Hour Shifts per Day), 7 Days per Week: Total of 168 Hours per 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: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

This case involves a female patient with a history of coronary artery disease (CAD), proximal left anterior descending (LAD) percutaneous coronary intervention (PCI), hypertension (HTN), and hyperlipidemia who presented to the emergency department (ED) with worsening shortness of breath for the last 2 weeks associated with left sided chest pressure radiating to the left shoulder. Her chest pain episodes were nonexertional. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm. The patient was admitted to the telemetry service under an inpatient level of care for evaluation of possible acute coronary syndrome (ACS). Cardiac troponin levels were negative. Cardiology service was consulted and recommended a coronary angiogram which revealed the patent LAD stent and no other obstructive CAD. Her left ventricular end-diastolic pressure (LVEDP) was elevated, 21 millimeters of mercury (mmHg). The echocardiogram showed normal cardiac function with no significant valve disease. The patient symptoms were attributed to acute pericarditis, and she was treated with a trial of colchicine. The patient's symptoms improved, and she was discharged home. 
At issue is the medical necessity of the Inpatient Stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. 
An inpatient level of care was not medically necessary in this case given that the patient's presentation was unlikely due to acute coronary syndrome (ACS), she remained hemodynamically stable, there were no ischemic electrocardiogram (ECG) changes, and cardiac troponin levels were negative. Furthermore, recent outpatient stress testing was negative for ischemia on myocardial perfusion imaging suggesting new occlusive CAD was less likely.  The patient presented with chest pain and shortness of breath with atypical features for ACS. Based on the well-validated Heart Pathway, peer reviewed medical literature, and American College of Cardiology (ACC)/American Heart Association (AHA) expert consensus guidelines on patients presenting to the ED with chest pain, an inpatient level of care was not appropriate or medically necessary for evaluation of chest pain in this case. (1-3) 

Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Problems. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Fasenra Pen. 
The denial is upheld.

The patient is a male with asthma. The request is for Fasenra. He is using Fasenra with Dupixent. The request was denied as he is using two biologics for his asthma. The subject under review is the medical necessity for the Fasenra Pen.

The health plan's determination is upheld in whole.

the Fasenra Pen is not medically necessary for this patient.
Benralizumab (Fasenra) is indicated for the add-on maintenance treatment of severe asthma in adults and adolescents with an eosinophilic phenotype. In two randomized trials (SIROCCO and CALIMA), add-on benralizumab treatment significantly reduced the annual exacerbation rate and improved lung function compared with placebo in adults and adolescents with severe, uncontrolled asthma with eosinophilic phenotype. In the randomized ZONDA trial in adults, benralizumab significantly reduced the glucocorticoid dose from baseline, but found no significant improvement in forced expiratory volume one second (FEV1) at 28 weeks. Patients received benralizumab 30 milligrams (mg) every 4 weeks or benralizumab 30 mg every 4 weeks for the first 3 doses and then every 8 weeks and all patients continued background asthma therapy.
The primary endpoint for Trials 1 and 2 was the rate of asthma exacerbations in patients with baseline blood eosinophil counts of greater than or equal to 300 cells/microliter (L) who were taking high-dose inhaled corticosteroids (ICS) and long acting beta agonists (LABA). Subgroup analyses from Trials 1 and 2 identified patients with a higher prior exacerbation history and baseline blood eosinophil count as potential predictors of improved treatment response. Reductions in exacerbation rates were observed irrespective of baseline peripheral eosinophil counts; however, patients with a baseline blood eosinophil count = 300 cells/L showed a numerically greater response than those with counts less than (<) 300 cells/L. In both trials patients with a history of 3 or more exacerbations within the 12 months prior to FASENRA randomization showed a numerically greater exacerbation response than those with fewer prior exacerbations.
In this case, the patient is using Fasenra with Dupixent. There are lack of robust studies to show safety and efficacy of dual biologic and this would not be standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis.

Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is upheld.

This case involves a male who presented to the emergency room with abdominal pain in the right lower quadrant and difficulty urinating. An abdominal computed tomography (CT) scan showed acute appendicitis. The patient was subsequently admitted to the pediatric unit and underwent a laparoscopic appendectomy. The inpatient admission was subsequently denied coverage claiming that there was no high risk for thromboembolism or need for bridging anticoagulation. The patient was not an infant and there were no inferencing complications during or after the procedure requiring a high intensity of service. Additionally, there was no record of pneumonia, respiratory distress, or signs of systemic infection or inflammation. The patient had no history of risk factors/comorbidities and examination did not report ascites, elevated bilirubin more than 3, cholecystitis, constipation, impaction, reflux, hemochromatosis, encephalopathy, ileus, inflammatory bowel disease, or pancreatitis. The appeal was that the patient required intravenous hydration, intravenous antibiotics, and intravenous pain control.  
The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

According to the Milliman Care Guidelines 25th Edition pertaining to a pediatric appendectomy without abscess or peritonitis, the goal length of stay is ambulatory 1 day postoperative. Indications for extended stay beyond goal length of stay may be needed for patients who have prolonged fever, complicated appendicitis, complications in general to include wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction, for patients with prolonged ileus, or postoperative bleeding.  The information provided for the review did not support that the patient required the extended inpatient care despite claims that he was receiving intravenous hydration, antibiotics, and pain control. These services could have been rendered on an observational basis and did not require the inpatient level of service. Given these findings, the inpatient admission was not medically necessary.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/Chronic Obstructive Lung Disease/COPD
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistant hours as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a past medical history significant for chronic obstructive pulmonary disease (COPD), hypertension, heart disease, heart failure, diabetes mellitus type 2 with neuropathy, venous insufficiency, osteoarthritis, lumbar spine disease, unsteady gait, and dizziness. She has had recent treatment for breast cancer.
This review is for the medical necessity for personal care services (PCA) 56 hours a week. The patient is currently approved for 40 hours a week. 

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service is medically necessary for this patient.
The Uniform Assessment System (UAS) state of New York was reviewed. The tasking tool noted 27 hours a week of services. The UAS State of New York performed at a later date was reviewed. The tasking tool noted 22 hours a week of services.
The latest UAS State of New York documents that the patient needs extensive assistance with bathing, limited assistance with dressing lower body, limited assistance with walking, living assistance with local motion, limited assistance with toilet transfer and extensive assistance with toilet use. It is reasonable say that the patient's medical condition has deteriorated since the last evaluation. There was a change in her evaluations. 
However, I think more of the change in her deterioration came subsequent to the last evaluation, which was supported by a note provided by her physician, who has stated that the patient has been diagnosed with breast cancer and subsequently received chemotherapy every 3 weeks and is currently started with radiation therapy. Due to the underlying nature of her illness and side effects of the current treatment regimen which aggravate fatigue, it is recommended to increase the services to 8 hours per day 7 days a week, as requested by the patient. Since the patient currently lives alone; an additional 2 hours a day of services would be beneficial for her to maintain her independence.
The health plan's decision is overturned. Additional services are necessary due to the patient's underlying medical conditions, with a new diagnosis of breast cancer and treatment including chemotherapy and radiation.
Appeal type: Medical necessity
Decision: Upheld

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

The patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) fatigue, chills, myalgias and nausea/vomiting associated with diarrhea. Vital signs were notable for tachycardia. The physical exam was notable for no apparent distress (NAD). Lab work was notable for a left shift, mild hyponatremia and transaminitis. A computed tomography (CT) scan of the head showed no acute findings. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with gastroenteritis and a urinary tract infection (UTI) and treated with intravenous fluids (IVF), intravenous (IV) antibiotics, pain control, anti-emetics, and electrolyte repletion. The patient was discharged in stable condition. At issue is the medical necessity of the inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with c/o fatigue, chills, myalgias and nausea/vomiting associated with diarrhea. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, while the patient had electrolyte abnormalities, she responded to electrolyte repletion, and did not have bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, the tachycardia responded to fluids, and there was no pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with acute gastroenteritis with dehydration, was treated and responded to IVF, anti-emetics, and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.