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

Diagnosis: Balanitis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient was an uncircumcised child who presented with respiratory symptoms, fever of 103 degrees Fahrenheit, coughing and vomiting twice a day for about 3 days, as well as penile pain. 

Abnormal labs included a urinalysis with 11 to 20 WBC's (White Blood Cell Count), and influenza A positive. On examination, the penis head was swollen and red with a small amount of white discharge. The diagnosis was balanitis involving the distal 1/3 of the penis with erythema. The erythema extended beyond the glans penis to the groin area and there was tender bilateral lymphadenopathy period, raising concern for spreading infection, including possible streptococcal etiology. The diagnosis was balanoposthitis versus penile cellulitis, leading to the decision to admit to the hospital for intravenous antibiotics. The child was started on IV (intravenous) Clindamycin. The erythema was noted to have increased compared to the picture documented from the GU (genitourinary) consult, so ceftriaxone was added to cover possibility of E. coli (Escherichia coli). 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. As discussed in Tews et al, in young children such as the patient, application of topical antibiotic ointment, in conjunction with systemic antibiotics if staphylococcal or group A streptococcal balanoposthitis or cellulitis is suspected, is the treatment regimen of choice. The route of administration would be oral antibiotics, although initially intravenous antibiotics can be given during a period of close observation, as was necessary in this case, because of the spreading erythema. However, there was no evidence of a fasciitis or gangrene. An admission level of care was not justified, especially as there was no urinary obstruction from the balanoposthitis. 

The inpatient admission is not considered medically necessary for this patient. An observation level of care would be adequate. 

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: substance abuse.
treatment: Inpatient Substance Rehabilitation Admission. 
The insurer denied Inpatient Substance Rehabilitation Admission. 
The health plan's determination is upheld. 

The patient is an adult female who was self-referred and admitted to inpatient rehabilitation substance use disorder treatment of severe stimulant (cocaine) and cannabis (marijuana) use disorders. The patient had relapsed while living in a sober house. The patient has a history of poly-substance with progression of the disease since young adulthood and escalating use of substances. She was also tobacco dependent.

The requested Inpatient Substance Rehabilitation Admission was not medically necessary for this patient.

The Inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated, understood the need for treatment and was capable of effectively participating in substance use disorder treatment in a less restrictive treatment setting. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for the mood, anxiety, and trauma related disturbances.

There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: liver disease (recent transplant).

Treatment: personal care assistance (PCA) services.

The insurer denied coverage for personal care assistance (PCA) services.

The denial is upheld.

This is an adult with medical problems including liver disease (recent transplant), history of brain abscess (status craniotomy and abscess drainage) and resultant aphasia.  He lives in a studio apartment.  The patient requested personal care assistance (PCA) services, denied by the insurer and currently under review.  

The Uniform Assessment System (UAS) report is recent.  The patient's cognition is described as minimally impaired.  He is reportedly totally dependent for much of his Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping.  The patient indicates his siblings assist with IADL tasks.  However, he is otherwise independent with activities of daily living tasks including bathing, personal hygiene, dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation (without a device).   The patient is fully continent of bowel and bladder.  There has been no functional decline or reported falls over the prior 90 days.  

The patient's condition and functional deficits are not at a level or unpredictable as to require PCA services. The patient may require additional monitoring, particularly due to his reported cognitive deficits.  However, safety monitoring under PCA does not include monitoring an individual when no other Level I or Level II personal care service task is being provided.   Due to his level of functional independence, the clinical records do not support the medical necessity of the patient requiring PCA services at this time.  

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 personal care assistance (PCA) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), diabetes, and sleep apnea who presented with chest pain.  A cardiac catheterization demonstrated a severe right coronary stenosis. He presented for elective percutaneous intervention of the right coronary artery. The left ventricular ejection fraction (LVEF) was normal. He underwent a successful and uncomplicated coronary artery intervention. His vital signs were essentially normal. He remained in no acute distress and was stable. He was discharged. At issue is the medical necessity of an inpatient stay.

This patient underwent successful elective and nonemergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example observation or outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease, hypertension and osteoarthritis.
Treatment: Personal Care Worker Service via Consumer Directed Personal Assistance Services (CDPAS) 8 hours per day/5 days a week, 4 hours per day/2 days a week, for a total of 48 hours per week.

The insurer denied coverage for Personal Care Worker Service via Consumer Directed Personal Assistance Services (CDPAS) 8 hours per day/5 days a week, 4 hours per day/2 days a week, for a total of 48 hours per week.  The denial is upheld. 

This is an elderly patient with chronic medical problems including Alzheimer's disease, hypertension and osteoarthritis.  She lives with her niece who is the paid caregiver (and also provides informal care) in a private residence.  The patient is approved for consumer directed personal assistance services (CDPAS) 8 hours a day/5 days a week, for a 40 hours per week.  The request is for CDPAS 8 hours a day/5 days a week, 4 hours per day/2 days a week, for a total of 48 hours per week.

The Uniform Assessment System (UAS) report is dated very recently.  The patient's cognition is minimally impaired.  She is reportedly totally dependent to extensive assistance for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing and toilet use.  Limited assistance is reportedly needed for bed mobility, locomotion, toilet transfer and ambulation (quad cane).  The patient is reportedly able to walk 1-2 blocks with periodic rest breaks.  She is frequently incontinent of bladder and occasionally incontinent of bowel.  She is independent with eating.  

There has been no change in her functional ability or reported falls over the prior 90 days.  Her functional ability is much the same when compared to the prior UAS report.  The patient may require additional monitoring, particularly due to her reported cognitive deficits.  However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  In addition, the patient has only 1 personal assistant (PA) with no secondary or back-up.  CDPAS regulations allow the aide to work a maximum of 40 hours/week.  As documented in the case notes, "When offered traditional aide service, PA/niece (who also provides informal care) confirms "traditional aide service is not an option."  Based on the records reviewed and CDPAS regulations, the patient's health and safety in the home can be appropriately provided and maintained by the currently approved CDPAS 40 hours/week.

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 personal care worker service via consumer directed personal assistance services (CDPAS) 8 hours a day/5 days a week, 4 hours per day/2 days a week, for a total of 48 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay
Treatment: Root Canal (D3320) on Tooth # (number) 13
The insurer denied the root canal (D3320) on tooth #13.
The denial is overturned.

The patient is an adult female requesting root canal therapy on tooth # (number) 13. The prior denial was because there are at least eight back teeth that touch when chewing; therefore, the root canal was denied.

The proposed treatment is medically necessary.

Tooth #13, the upper left second premolar, has deep decay into the nerve. The tooth can definitely be restored (after the root canal procedure) with a crown. Removal of this restorable tooth is not in the patient's best interest. Other upper teeth may start to shift if that tooth is not there and this will cause an uneven bite on the patient's left side. The tooth should be treated and saved instead of extracted, to preserve the integrity of the dentition and prevent an uneven bite from developing. The root canal procedure is medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Anemia, diabetes, dementia, bipolar disorder, schizophrenia, heart disease, benign prostatic hypertrophy (BPH), and legal blindness

Treatment: consumer direct personal assistance services (CDPAS) 24 hours a day, 7 days a week (split-shift) totaling 168 hours

The insurer denied coverage for consumer direct personal assistance services (CDPAS) 24 hours a day, 7 days a week (split-shift) totaling 168 hours

The denial is modified

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired." The patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) including meal preparation, ordinary housework, and shopping. The patient requires extensive assistance for bathing, personal hygiene, dressing, locomotion, ambulation, and toilet transfer/use. The patient is infrequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and eating. There were no falls or hospitalizations over the prior 90 days. The combination of the patient's cognitive deficits and functional decline support the medical necessity of increasing Consumer Directed Personal Assistance Services Program (CDPAS) to 84 hours per week. The patient may require additional monitoring, particularly due to memory and balance deficits. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by increasing CDPAS to 84 hours/week. 

From a physical medicine and rehabilitation perspective, the requested CDPAS 24 hours a day, 7 days a week (split-shift) totaling 168 hours are not medically necessary. However, CDPAS 84 hours/week are medically necessary. 

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 consumer direct personal assistance services (CDPAS) 24 hours a day, 7 days a week (split-shift) totaling 168 hours is not substantiated. However, CDPAS 84 hours/week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient is a young adult who has asthma. She presented to the emergency department (ED) with complaints of shortness of breath (SOB), chest tightness and wheezing. The patient had been seen in the ED the previous day for the same symptoms. The patient was treated with nebulizers and discharged home on Prednisone. The patient did not fill her Prednisone prescription and returned to the ED. In the ED, the vitals were T (temperature) 97.2 degrees F (Fahrenheit), Heart Rate 97, Respirations 18, Blood pressure 119/67. The patient was not in any acute distress. There was no use of accessory muscles. She was speaking in full sentences. The lung exam revealed expiratory wheezing. The patient was treated with Nebulizers and Steroids in the ED. Labs at presentation included white blood cells (WBC) of 7.4. The rest of the electrolytes were unremarkable. Phosphorus was low. The Influenza A screen was positive. The chest x-ray showed no infiltrate or effusion. An Electrocardiogram (EKG) showed No acute ST-T (intervals on an EKG) changes. The venous blood gas was 7.38/38/43 and 76 % (percent). The patient was admitted to the hospital for an asthma exacerbation. The patient improved with treatment with Oral Steroids, long-acting beta-2 agonist / inhaled corticosteroids inhaler and bronchodilators via nebulizer. The patient was given Tamiflu. The patient was subsequently discharged home with an outpatient follow up.
This patient did not need an acute inpatient hospitalization. The patient could have been placed in observation status which could have been for up to 48 hrs (hours). The patient could have had diagnostic testing and treatment done while she was in observation. As per the notes, the patient had improved with treatment in the ED. She was afebrile and stable. The patient was not hypoxic. No use of accessory muscles or any respiratory distress was documented. No pneumonia was noted. The patient had some elevated Lactate which was in the setting of nebulizer use and has been described with use of nebulizers. The patient could have been discharged home on oral steroids and bronchodilators after a period in Observation with further close follow up in the outpatient setting. The patient had not shown improvement initially after the first emergency department visit as she had not filled her steroid prescription. The patient was treated with oral steroids after admission, and she improved.

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

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The health plan acted reasonably. Based on clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department with complaints of abdominal pain. The patient was admitted and underwent an uneventful laparoscopic appendectomy and was discharged the day after admission. There were no reported complications. Outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation. 

The acute inpatient hospital stay was not medically necessary. Per clinical documentation, the patient presented to the emergency department with a one-day history of periumbilical abdominal pain. Vital signs were significant for an elevated blood pressure of 161/91. White blood cell count was 14.86. A Computed Tomography scan was positive for acute appendicitis. The patient underwent an uneventful laparoscopic appendectomy and was discharged on the same day. There were no reported complications. Admission may be necessary for patients with severe systemic illness (such as sepsis), poorly controlled comorbidities (such as Chronic Obstructive Pulmonary Disease, chronic heart failure), or complications from the procedure (such as infection, bleeding) that require more than 24 hours of postoperative care. There were no immediate complications documented after the surgery. Peer-reviewed literature also indicates that outpatient laparoscopic appendectomy can successfully be performed in those with uncomplicated appendicitis. Suitable criteria for same-day discharge includes hemodynamic stability, tolerating liquids, and pain controlled on oral medications. Therefore, the requested inpatient hospital stay was not medically necessary. Observation care would be more appropriate. 

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: Overturned

Diagnosis: Dental caries
Treatment is core buildups on teeth numbers 6 and 9
The insurer denied coverage for core buildups on teeth numbers 6 and 9
The denial is overturned.

Based on the submitted documentation which includes copies of mid treatment, endodontic, and pretreatment radiographs as well as periapical and full mouth series radiographs, clinical notes, and insurer correspondence, it appears that this patient presented for dental care. Failing long-standing direct placement restorations were noted on teeth #6 and #9 and replacement of these restorations after caries excavation served as the core buildups prior to crown preparation for these teeth to be abutments in a long span fixed bridge. The insurer has approved the crowns for these teeth but has denied the core buildups stating that the service is not medically necessary, as the documentation did not demonstrate clinical findings to support the treatment, and therefore the circumstance does not fulfill the insurers stated criteria for approval. 

Upon review of radiographs and clinical notes, it supports the recommended treatment. Teeth #6 and #9 exhibit a failing direct placement restorations with caries. There would be ample coronal structure remaining after core buildup. The teeth will then have adequate coronal structure for support of full coverage crown and adequate residual periodontal alveolar bone height. 

The standard of care in general dental practice would be as suggested. Further, the clinical situation meets the insurer criteria.

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 core buildups on teeth numbers 6 and 9 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting. 
Treatment: Inpatient hospital admission. 

The health plan denied: inpatient hospital admission. 
The determination is upheld. 

The patient is a male with past medical history of recent avulsion laceration to the right middle finger who was admitted with complaints of bilateral hand cramping with nausea/vomiting. His vital signs were notable for a pulse of 115 beats per minute (bpm). The physical exam was notable for avulsion laceration to tip right middle finger, no hand swelling, warmth, discharge, or tenderness to palpation (TTP), positive (+) tetany to bilateral hands. The lab work was notable for a potassium of 3.3 and a normal calcium. The electrocardiogram (EKG) showed prolonged QTc. The patient was diagnosed with hypokalemia and treated with intravenous fluids (IVF), potassium, and calcium gluconate. The patient was discharged on in stable condition. 
At issue is the medical necessity of the inpatient hospital admission. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. The patient presented to the emergency department (ED) with complaints of bilateral hand cramping with nausea/vomiting. The patient was found to have a decreased potassium to 3.3 associated with muscle cramps. The patient was non-toxic appearing, had a potassium greater than 2, and no severe symptoms, such as ileus, rhabdomyolysis, respiratory muscle weakness, ascending paralysis, or ventricular dysrhythmias. The patient had lab errors on the initial venous blood gas (VBG), which were not found to be consistent with the basic metabolic panel (BMP) drawn near the same time as the VBG. This patient presented with a history of nausea and vomiting, received electrolyte repletion, and symptomatically improved, and these interventions could have been safely provided at an alternate level of care.