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

Diagnosis: Postpartum endometriosis 
Treatment: Acute inpatient stay 

The insurer denied coverage for acute inpatient stay. The denial is overturned. 

This patient is a female who presented to the Emergency Department (ED) several days after a normal vaginal delivery, complaining of fever (i.e. temperature of 40 C) and abdominal pain. The patient's initial exams showed elevated pulse rate of 115 bpm, temperature of 39.5, suprapubic area tenderness, uterine tenderness, and foul smelling vaginal discharge. Initial lab findings showed elevated white blood cells (WBC) of 13.39, and low hemoglobin of 7.5, hematocrit of 23. The patient was admitted with the diagnosis of postpartum endometritis. The patient was started on intravenous (IV) antibiotics. Evaluation showed that the patient was afebrile, and her pain was improved. The patient was discharged home on oral antibiotics. 

Postpartum endometritis is a common cause of postpartum febrile morbidity on any 2 of the first 10 days postpartum, exclusive of the first 24 hours. The infection is polymicrobial, usually involving a mixture of two to three aerobes and anaerobes from the lower genital tract. The diagnosis of postpartum endometritis is based upon clinical criteria of fever and uterine tenderness occurring in a postpartum woman.  Other signs and symptoms which support the diagnosis include foul lochia, chills, and lower abdominal pain. This patient had endometritis. Admission to the hospital for IV antibiotic, and to rule out sepsis was medically necessary. 

As per the MCG guidelines, endometritis is considered a clinical indication for admission to inpatient care. Treatment of postpartum endometritis is indicated for relief of symptoms and prevention of sequelae. Parenteral antibiotics are administered until the patient is clinically improved and afebrile for 24 to 48 hours. 

Based on the above, this patient's admission was medically necessary. Once she was afebrile and clinically improved she was discharged home. This is consistent with standard of care. 

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

The carrier's denial of coverage for the acute inpatient stay should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder 
Treatment: Acute Inpatient Stay 

The insurer denied coverage for acute inpatient stay. The denial is upheld. 

This patient is a female who presented to the Emergency Department with a chief complaint of left peri-oral numbness with left upper extremity weakness with repetitive bouts of tingling and numbness in the left hand. She also noted increased temperature. She was admitted to the hospital and underwent MRI/MRA of the brain on recommendation of neurology. MRI was negative for acute stroke. MRA showed M1 intracranial stenosis. She was placed on Plavix. At issue is the medical necessity for the entire inpatient hospitalization. 

This patient has a past medical history that includes hypertension as well as MCA stroke secondary to cerebral vasoconstriction syndrome. She presented with complaints of left upper lip numbness as well as left first second and third fingertip numbness x1 week. She indicated 10 days prior she had a temperature followed by 3 days of diarrhea. Since that time, she has had daily episodes of left second digit distal fingertip numbness and left thumb distal fingertip numbness lasting for a few minutes and then it goes away. One day prior she also had left upper lip numbness that she has not had before. She does utilize aspirin and enalapril daily. The physical examination revealed 5/5 strength to the bilateral upper and lower extremities. The patient's vital signs included a blood pressure of 113/77 with a pulse of 74 bpm. The documentation detailed that given a lack of further adverse events she was discharged. 

The patient presented with left-sided peri-oral numbness with intermittent waves of numbness in the left upper extremity. She underwent MRI/MRA of the brain on recommendation of neurology. MRI was negative for acute stroke. MRA showed M1 intracranial stenosis. Diagnostic work up with MRI/MRA of the Brain could have been performed in the ED setting and/or on an observation along with neurological consultation and inception of therapy with Plavix along with expeditious follow up with neurology on an outpatient basis. Care provided did not warrant in-patient hospitalization. 

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

Based on the above, the medical necessity for the acute inpatient stay is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic /musculoskeletal/joint problem.
Treatment: Inpatient hospital.
The insurer denied the entire inpatient hospital stay.
The denial is partially overturned.

This case describes a patient who underwent a right primary total knee replacement surgery. The records document that the patient has a history of hypertension and that she failed conservative treatment for advanced osteoarthritis of the right knee.
Yes, in part, the requested inpatient hospital stay was medically necessary for this patient. Based on the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature, the inpatient hospital admission was medically necessary for this patient for 2 nights. The two additional days of inpatient care were not medically necessary.
The rationale for this determination is based upon the provided medical records which document that this patient underwent primary right total knee replacement surgery. The progress notes subsequently documented that the patient had a reported pain level of 10/10 and was not able to participate in her afternoon physical therapy session due to her increased pain level after surgery. The records then document that the patient received appropriate pain medications and was able to participate more fully in physical therapy the following day.  In fact, the patient was able to ambulate 30 feet. The patient  was able to negotiate 4 stairs in therapy that day as well. The recommendation of the therapy department was for discharge to home with home physical therapy based upon  progress. Based on the documentation the inpatient hospital stay was medically necessary for appropriate pain control. The two-night hospital admission was also medically necessary to allow sufficient progress with supervised physical therapy such that the patient could safely continue her recovery at home. The additional two night inpatient stay, however, was not medically necessary based on the provided medical records.
The medical necessity of the inpatient hospital stay for two nights is established based on the provided medical records and is consistent with the recommendations of the current, peer-reviewed orthopedic literature as published by Xu and colleagues and by Springer and associates.
Appeal type: Medical necessity
Decision: Overturned

Substance Abuse
Substance Abuse: Inpatient

Diagnosis: Substance Abuse
Treatment: Inpatient Detox

The insurer denied the inpatient detox treatment. The health plan's determination is overturned. 

The patient is an adult male who presented for inpatient detoxification treatment to address a severe substance use disorder with an opioid class substance of abuse. He was self-referred following a relapse that followed two years of sobriety and past treatment for substance use disorder that had occurred five years prior to presentation. The patient has a history of heroin use with intravenous (IV) administration in the past and current use with up to 8 bags of heroin daily with intranasal administration. The patient was noted to be hepatitis C positive.

The patient has a history of detoxification treatment as noted. He provided no history of psychiatric disorder or treatment and denied use of other substances except for tobacco.

The Inpatient Detoxification Treatment is medically necessary for this patient. The treatment of this patient's substance use disorder with detoxification and withdrawal management did require the structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment. Additionally, he had a treatment history with relapse that supported the necessity for an inpatient level of care, and presented with moderately severe withdrawal symptoms. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications. 

The patient's history of opioid use did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with achieving abstinence from opioid use disorder.

Thus, the patient did require a safe and effective detoxification treatment with Inpatient Detoxification and Withdrawal Management through discharge, as it was foreseeable that the patient was unable to abstain from use of opioid or maintain abstinence if detoxification were to be attempted at a lower level of care. Moreover, the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria did warrant the admission and did also warrant the continued inpatient level care through discharge.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plantar Fasciitis
Treatment: Orthotics
The health plan denied the requested custom molded orthotics. The health plan's determination is upheld.

The patient is a male who presented with a chief complaint of ingrown nails, interdigital tinea pedis and for evaluation of custom orthotics. During this examination there was no mention of plantar fasciitis problems. There were no treatments for plantar fasciitis.
On the office visit the patient presented with heel pain and plantar fasciitis. The treating provider recommended he not walk barefoot and asked him to wear his old orthotics. He also recommended stretching. There are no other follow up notes regarding the initial treatment progress for plantar fasciitis. The treating doctor is requesting custom molded orthotics.
The standard of care for treatment of plantar fasciitis had not been established in review of the progress note.

The decision of the health plan that medical necessity has not been established for the use of custom molded orthotics is upheld, in whole.

No. The plantar fascia is composed of compacted collagen fibers that run mainly longitudinally on the plantar aspect of the human foot. The plantar fascia originates from the medial calcaneal tuberosity, and travels distally via several slips, also known as medial band, central band and lateral band. These bands are inserted distally in the intermuscular septa. When these bands become inflamed, they cause pain and discomfort. The term plantar fasciitis refers to the inflammation of the plantar fascia bands. It has been established that mechanical overload of the plantar arch causes increased tension of the plantar fascia which can lead to straining of the ligament and plantar fasciitis.
The American College of Foot and Ankle Surgeons (ACFAS) published clinical practice guidelines for treating plantar heel pain. The recommendations are rest, ice, elevation, shoe modification, non-steroidal anti-inflammatory medication, cortisone injection therapy, physical therapy, and biomechanical support (strapping, over the counter orthotics ) of the plantar arch (fascia). When conservative treatments have failed surgical intervention may be recommended. Custom orthotics are recommended for long term management after the initial treatments have been performed.
In the case study reviewed there is only one office visit progress note that discussed the diagnosis of plantar fasciitis and treatments. The note states the doctor recommended stretching, avoid walking barefoot, and wearing orthotics.
The standard of care recommended treatments for plantar fasciitis are, rest, ice, elevation, shoe modification, non-steroidal anti-inflammatory medication, cortisone injection therapy, physical therapy, and biomechanical support of the plantar arch (fascia).
In the above case study, the standard of care treatments were not prescribed except for stretching. There is no follow up progress note on how the patient was responding to the treatments. The medical necessity request for custom molded orthotics has not been established.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient Hospital

Diagnosis: Altered mental status
Treatment: Inpatient Hospital
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man with a history of Down syndrome, hypertension and seizures who was admitted to the hospital. He presented to the emergency department because of altered mental status. His mother reported that his balance was compromised. She also reported that he was having difficulty walking. He had a permacath that had clogged during dialysis three days prior to presentation. He was scheduled for permacath removal and insertion. Vital signs showed blood pressure 126/70, heart rate 77, temperature 98.2 Fahrenheit, and respiratory rate 17. On physical exam, heart was regular, breath sounds were unlabored, and the abdomen was soft and nontender. Labs showed white blood cell (WBC) 6.4, hemoglobin 9.5, platelets 188, sodium 140, and potassium 5.0. Head computed tomography (CT) was negative for acute stroke. Chest x-ray was negative for pneumonia. The patient was admitted for permacath dysfunction and altered mental status. 

The inpatient stay was not medically necessary. He primarily underwent permacath revision during the hospital stay, and this is an outpatient procedure. He had no evidence of sepsis, hemodynamic instability, acute seizures, acute stroke, acute electrolyte abnormalities, or ingestion causing his altered mental status. The presentation was not consistent in acuity with an inpatient medical stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain and hematemesis.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is overturned. 

This is a female patient with a past medical history of nicotine abuse and alcohol abuse.  The patient presented to the Emergency Department (ED) with subjective complaints of vomiting blood and abdominal pain.  She drank daily and had 2 to 3 cups of tequila on the date of presentation.  She had 5 hours of intermittent dark red/brown bloody vomit associated with epigastric pain.  The patient denied fever, chills, chest pain, shortness of breath, trauma, or weakness.  The patient's blood pressure was 127/87.  Her temperature was 97.5.  Her heart rate was 81 beats per minute.  She was disheveled and was well-nourished, awake, alert, oriented to person, place, and in mild distress.  The patient's bowel sounds were normal in all 4 quadrants.  There was tenderness to palpation in the epigastric region.  Her hemoglobin level was 13.9 and her hematocrit was 41.0.  Her platelet count was 219.  A computed tomography (CT) scan of the abdomen and pelvis with contrast was normal.  There was no evidence of mechanical bowel obstruction or acute inflammatory disease.  There was no evidence of ascites or adenopathy.  The patient's chest X-ray revealed no evidence of active pulmonary disease.  The provider noted that the patient could not be safely discharged home and required further management.  The patient had a medical necessity to be admitted as the care was beyond the capabilities of the ED for possible gastrointestinal bleed, alcohol gastritis, intractable vomiting and no evidence of COVID-19.  The patient was admitted with abdominal pain and hematemesis. Gastroenterology (GI) consulted over the case and it was recommended that the patient's complete blood count (CBC) be monitored, and that she be treated with intravenous (IV) fluids, IV proton pump inhibitors (PPI) twice a day, transfused if needed and an abdominal ultrasound (US) be considered if there was an acute elevation in liver function tests (LFTs).  The patient also received pain medication during the admission.  The patient was stabilized and discharged on day 2 of admission. 

The patient was acutely ill, and she was not in a position to be treated via outpatient observation.  The inpatient admission is considered medically necessary for this patient. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems. 
Dental/Orthodontic Procedure. 

Diagnosis: Dental Malocclusion. 
Treatment: Braces. 

The insurer denied Braces. The health plan's determination is overturned. 

The patient in question is a female with a Class I malocclusion and anterior crossbite of tooth #9. Tooth #24 is displaced labially due to the crossbite and already has significant recession. She is treatment planned for orthodontics to correct malocclusion. This is under review. 

Braces are medically necessary for this patient. The patient has maxillary anterior crowding with tooth #9 in crossbite. Tooth #24 already has significant recession that will likely require future periodontal surgery. Delaying treatment will lead to further labial movement of tooth #24 which could very well lead to the loss of this tooth. Orthodontic treatment now will save tooth 25. Braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: history pertinent for COPD (chronic obstructive pulmonary disease), Hypertension, CHF (congestive heart failure), Depression, Insomnia, Cervical spinal disease, Parkinson's disease and Diabetes Mellitus
Treatment: Personal Care Assistant Services 84 hours per week
The insurer denied the Personal Care Assistant Services 84 hours per week.
The denial is overturned.

The patient is a female with past medical history pertinent for COPD (chronic obstructive pulmonary disease), Hypertension, CHF (congestive heart failure), Depression, Insomnia, Cervical spinal disease, Parkinson's disease and Diabetes Mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.

The patient is a female with past medical history pertinent for COPD (chronic obstructive pulmonary disease), Hypertension, CHF (congestive heart failure), Depression, Insomnia, Cervical spinal disease, Parkinson's disease and Diabetes Mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent correspondence from the patient's medical provider indicates that due to worsening gait ataxia, cognitive impairment and weakness, the patient's functionality and ability to perform ADLs (activities of daily living) has significantly decreased. For these reasons, the currently approved plan of 56 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. Hence, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrence of constipation of abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with history of chronic constipation with multiple admission to the hospital for it. She presented to the ED (emergency department) with recurrence of constipation of abdominal pain. The colonoscopy done had revealed descending and sigmoid colitis, and diverticular narrowing and stricture of the descending colon. The rest of the colon was normal. The terminal ileum was normal. The plan at the time of her discharge was to have surgical evaluation for possible segmental sigmoid colon resection.

During this admission, the patient was hemodynamically stable and afebrile. The CT (computed tomography) scan of the abdomen revealed moderately dilated colon but no obstruction, and mild ileitis. She was started on bowel regimen with Miralax and bisacodyl 10 mg (milligrams) suppository daily as per GI (gastroenterology) recommendations. She had several bowel movements with this bowel regimen. She was also was given IV (intravenous) normal saline for the mild hypotension that she developed after she had several bowel movements. She was discharged home with outpatient follow up with GI (gastroenterology) and further evaluation of her motility disorder.

No, the Inpatient admission was not medically necessary for the management of this patient.

The patient had a history of chronic constipation and had multiple admissions in the past for the management of chronic constipation. During this admission, she was hemodynamically stable and afebrile. Her abdominal pain was managed initially with IV (intravenous) morphine. She had a CT (computed tomography) scan of the abdomen, which revealed moderately dilated colon but no obstruction requiring any surgical intervention. Her constipation resolved after a bowel regimen of Miralax and Dulcolax suppository. She was discharged home on bowel regimen and follow up with GI (gastroenterology) and Motility center. Given this clinical scenario, she could have been safely and adequately managed at the lower level care.