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

Diagnosis: mobility
Treatment: home health care
The insurer denied Personal Care Services: 24 Hours per Day (Live-In) (Split Shift), 7 Days per Week.
The health plan's determination is upheld. 

This is a case review for a female with medical history notable for mobility issues and incontinence.  The patient's physician provided a letter of support for this appeal. The letter states that the patient would "benefit from an increase to having a significant decreasing ability to perform her activities of daily living" including bathing, grooming, and skin care. The patient needs hands-on assistance with personal care tasks.
The patient's geriatrician provided a letter of support. The letter states that the patient has gait instability. She has advanced degenerative joint disease. There is no discussion of unmet personal care needs.

The requested Personal Care Services: 24 Hours per Day (Live-In) (Split Shift), 7 Days per Week is not medically necessary for this patient.
The patient requires hands-on assistance for most activities of daily living (ADL). She is able to participate in her care and direct her care. Her cognition is intact. She will require assistance for most of the day. She does not have any clearly demonstrated night time personal care needs. Her incontinence episodes are very infrequent. She requested additional services to help with medications, transfers, ambulation, toileting and housework. The hours provided should be sufficient to cover for those needs. There is insufficient documentation that the patient has any personal care needs at night that are not currently being met. Therefore, the requested services are not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
treatment: Inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld

The patient is a young man who presented to the emergency department (ED) with one-day history of fever, more than ten episodes of vomiting over a two-hour period, headache, body aches, and fatigue. He had no diarrhea. Vital signs included temperature 39.8, heart rate 138, respiratory rate 20, and blood pressure 95/41. Examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, tachycardia, clear lungs, benign abdomen, and non-focal neurologic deficit. Labs were significant for white blood cell (WBC) count 9.6 with 92% (percent) neutrophils, carbon dioxide (CO2) 23, glucose 97, C-reactive protein (CRP) 0.2, venous potential hydrogen (pH) 7.38, lactate 2.2, procalcitonin 4.76, negative urinalysis, and negative rapid viral screen. Chest x-ray was negative.

The inpatient hospital admission was not medically necessary. This young man presented to the ED with acute onset intractable vomiting. He was febrile and hypotensive upon presentation but responded to two fluid boluses. He had no further vomiting, had no diarrhea, and was able to start eating and drinking. His vital signs stabilized and he was able to discharge home. While his blood pressure was low upon presentation, he had no clinical signs of hypoperfusion. He was alert and cooperative with good perfusion. While it was reasonable and medically necessary to monitor him in the hospital, he was over stable with rapid positive response to fluids and antipyretics. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

This patient had a history of eczema and progressively 6 days of progressively worsening rash on the arms, legs and trunk that was not responding to ointment. In addition, the patient had three days of fever. The patient's mother noted that the rash was peeling and itching. 

This reviewer agrees with the insurer that admission was not medically necessary, and that all of the testing done in the emergency room (ER) was sufficient to manage the patient's condition. The patient did not need aggressive fluid therapy as there was no evidence of being dehydrated. There was no evidence of eczema herpeticum.  Eczema herpeticum is a widespread herpes simplex virus infection of inflamed skin, in patients with atopic dermatitis or eczema. This is a clinical diagnosis based upon a monomorphic eruption of blisters or pustules in the eczematous lesions and entails a risk of severe systemic illness. It can rapidly involve extensive areas of skin with occasional systemic dissemination but resolves promptly with administration of intravenous acyclovir. As stated in reference #2, "if the patient has widespread eruptions or systemic symptoms such as fever, malaise, and poor oral intake, the patient should be admitted for intravenous acyclovir." The patient had a low grade fever 99.5 degrees Fahrenheit in the ER but there was no evidence of a systemic bacterial infection in addition to the mild possible staphylococcal superinfection. Moreover, the white blood cell (WBC) count was only borderline elevated. Moderately severe atopic dermatitis, bacterial super infection possible staph, eczema herpeticum and viral syndrome are all mentioned in the assessment and plan, but a  specific rationale or justification for admission is not described. Pediatric history and physical nodes generalized skin rash on entire body including face including macules papules vesicles and pustules with desquamation and peeling. It documented 2-3 areas of 1 to 2 centimeters skin peeling, however, this description is not specific enough to indicate Staph Scalded Skin Syndrome. Other than the borderline leukocytosis of just over 15,000, all the lab parameters were within normal limits, and temperature recorded in the ER was low grade. The patient was not toxic appearing and was alert and active. 

Instead, my clinical impression from the records presented is generalized impetigo superimposed on a flare of atopic dermatitis. Impetigo is not a systemic or bacteremic infection, although it makes the child uncomfortable. Treatment consists of systemic antibiotics, always oral (see reference 3, section on extensive impetigo and ecthyma), preferably clindamycin, and minimal use of topical medications for the skin. 

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: cellulitis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with a medical history of diabetes mellitus, hypertension, hyperlipidemia, and a previous deep vein thrombosis who was referred by his primary care physician due to leg pain and mild drainage. The patient denied experiencing recent fever, chills, headaches, unintended weight changes, and vision or hearing problems. There were no signs of paroxysmal nocturnal dyspnea, orthopnea, or peripheral edema. Concerns were raised about cellulitis and osteomyelitis, given the leg swelling and pain. Negative results from arterial and venous duplex studies were reported, which essentially ruled out deep vein thrombosis. 

The inpatient hospital admission was not medically necessary. This patient was admitted to the hospital with suspicion of cellulitis.
In general, admission at the acute inpatient level of care is indicated for patients with cellulitis who failed outpatient therapy, in cases of limb-threatening infection, or rapid progression of the infection that necessitated high-intensity monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus or liver cirrhosis.
Admission at the acute inpatient level of care is also indicated for patients with cellulitis associated with bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection, or oral cellulitis, or when patients need a surgical procedure not amenable to outpatient or emergency department care, cases of cutaneous gangrene, or when patients have severe pain requiring acute inpatient management, inability to maintain oral hydration, in cases of compartment syndrome, or some other conditions that were not relevant to this clinical case.
The review of the medical records did not show evidence that the patient had any of the circumstances justifying admission at the acute inpatient level of care for the treatment of cellulitis.
Based on my assessment, observation was reasonable to perform the necessary work up and determine if this patient really had cellulitis that would require treatment with antibiotics. The inpatient level of care was not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: home health care
The insurer denied Meals on Wheels (MOW) Home-Delivered Meal Services: 7 Days per Week, 2 Meals per Day (14 Meals per Week)
The health plan's determination is upheld. 

The patient is a male with past medical history of legal blindness, diabetes mellitus type 2, hyperlipidemia, hypertension, and varicose veins who had been assigned Meals on Wheels 2 times per day, 7 days/week, to total 14 days/week but services were discontinued following an increase/initiation of PCA (personal care aide) services noting the patient had a duplication of services as personal care worker plan comprised of meal preparation. 

Meals on Wheels (MOW) Home-Delivered Meal Services: 7 Days per Week, 2 Meals per Day (14 Meals per Week) are not medically necessary for this patient.
There is documentation that the patient is receiving PCA (personal care aide) services. As the plan stated, there would be duplication of services if the patient received meals on wheels as the patient's PCA care plan includes meal preparation. The patient requires a low salt and no concentrated sweet diet. Per the most updated Home Health Aide Matrix Permissible and Non-Permissible Activities Home Health Aide (HHA) Services from NY State DOH (Department of Health), 2009 the PCA/HHA is able to prepare meals in accordance with complex modified diets including combination of two or more modified diets. The PCA under the instruction of the patient's medical provider, and dietician utilizing the patient's own meal preferences is able to prepare meals for the patient during the currently assigned PCA service hours. In addition, the patient does not require the use of insulin with his diabetes and therefore is not at risk for hypoglycemic episodes which could result from missed or skipped meals. In summary, the Meals on Wheels (MOW) Home-Delivered Meal Services: 7 days/week, 2 meals/day (14 meals per week) are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypotension, acute kidney injury, and hyperosmolar hyperglycemic state
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is overturned.

The patient is an adult male. He presented to the hospital with weakness, fatigue, lightheadedness, and loss of appetite. He has a history of type 2 diabetes, hypertension, deep venous thrombosis/pulmonary embolism (DVT/PE) on Xarelto, hyperlipidemia, and obesity. He was found to have hypotension, acute kidney injury, and hyperosmolar hyperglycemic state. The patient was treated with intravenous hydration and insulin. The patient's electrolyte abnormalities, hypotension, hyperglycemia, and acute kidney injury resolved. The inpatient admission was denied coverage by the health plan as not medically necessary. The appeal was requested, because it is posited that all of the provided services could not have been provided as outpatient or as an observation and required an admission to the hospital.

The Inpatient admission was medically necessary.

The provided medical records show that the patient had hypotension, acute kidney injury, and hyperosmolar hyperglycemic state. The patient needed inpatient care in order to treat hypotension, acute kidney injury, and hyperosmolar hyperglycemic state. Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II Division 1 malocclusion 
Treatment: braces/monthly visits
The insurer denied braces/monthly visits.
The health plan's determination is overturned. 

The patient in question is a female with a Class II Division 1 malocclusion with maxillary and mandibular crowding. She has 7-millimeter (mm) overjet and 0 mm overbite. She is treatment planned for Braces and Monthly Visits (x [times] 12) to correct her malocclusion. This is under review.

Braces and Monthly Visits (x12) are medically necessary for this patient. 
This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. (1) Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ (plus) mm overjet, which this patient has. For these reasons, Braces and Monthly Visits (x12) are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective cardiac catheterization
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She had elective cardiac catheterization. Her PMH (past medical history) includes hypertension, hyperlipidemia, diabetes and known CAD (coronary artery disease) treated with PCI (percutaneous coronary intervention) x4, including DES (drug-eluting stent) to the mid LAD (left anterior descending) and a heavily calcified 90-95% mid RCA (right coronary artery) stenosis. The patient underwent staged, complex intervention of the RCA (right coronary artery), including PCI (percutaneous coronary intervention) with stent and Excimer laser atherectomy. There were no procedural complications. Following overnight observation, she was discharged to home. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. In this particular case, the patient underwent planned LHC (left heart catheterization) with complex PCI (percutaneous coronary intervention) of a heavily calcified RCA (right coronary artery) on the same day. The information provided does not support the medical necessity for admission after the patient's successful and uncomplicated coronary intervention. PCI (percutaneous coronary intervention) procedures are routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like ACS/AMI (acute coronary syndrome/acute myocardial infarction), CVA (cerebrovascular accident), contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip dysplasia
Treatment: Semi-electric hospital bed
The insurer denied the Semi-electric hospital bed.
The determination is upheld.

This is a male patient with cerebral palsy affecting his right lower extremity and neuromuscular subluxation of his right hip. He was ambulatory prior to the surgery and was described as being quite active. He was admitted to the hospital and underwent a right proximal femoral osteotomy and Pemberton acetabuloplasty. He received physical therapy after the surgery, including training of his mother with transfers to a wheelchair or recliner, turning in bed and diapering, and in the use of a Hoyer lift. He was discharged to home in the care of his family, with a prescription for a Hoyer lift and semi-electric hospital bed. At issue is whether the hospital bed should be considered medically necessary.

The patient had a major surgery on his right hip, and he is required to be non-weight-bearing on that hip for several weeks. He requires a great deal of care at home, including assistance for turning, diapering, and transfers. However, he received a thorough evaluation by physical therapy during his hospitalization, with several sessions of training, and was cleared for discharge to home in the care of his family with transfers accomplished using a Hoyer lift. He tolerated sitting in a wheelchair or recliner while in the hospital. He can be cared for safely at home in a regular bed. A hospital bed for home use would not be considered the standard of care after unilateral surgery of this type. It should not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: shortness of breath and wheezing
Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient is an adult male with history of asthma, hypertension, obstructive sleep apnea (OSA). The patient was on Continuous Positive Airway Pressure (CPAP) at home. He presented to the emergency department (ED) with complaints of shortness of breath and wheezing.

The patient had taken his albuterol at home without relief.

On presentation: Blood Pressure was 154/87 mmHg, Respiratory Rate 26 breaths per minute, Heart Rate 105 beats per minute and oxygen saturation was 92 percent on room air.

The patient was noted to have some decreased air entry on lung exam with bilateral wheezing.

The patient was treated with Duo Nebs and Oral Prednisone in the emergency department and subsequently admitted for Asthma Exacerbation.

The patient was alert and oriented times 3 and was in no apparent distress. After treatment in the emergency department: Temperature was 97.1 degrees Fahrenheit, Heart Rate 80 beats per minute, Respiratory Rate 17 breaths per minute and oxygen saturation was 98 percent on room air. Peak Expiratory Flow (PEF) was in 300's, lung exam mild wheezing with no use of accessory muscles.

White Blood Cell (WBC) count was 5.2K, hemoglobin 12.4.
Chest X-ray showed no acute infiltrates or effusion or pneumothorax. Computed tomography (CT) was negative for Pulmonary Embolism. Initial Venous Blood Gases (VBG) were 7.32/72/41 and repeat was 7.36/62/82.

The patient was continued on treatment with Oral Prednisone and Duo Nebs. 

After treatment, the patient reported feeling better and that his exacerbation had been caused by his running out of meds. Lungs were clear, CVS S1 S2 (heart sounds) were normal. The patient continued on Albuterol and Ipratropium Nebs and oral Prednisone.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. He had known asthma and obstructive sleep apnea (OSA). Lungs only mild wheeze which cleared up by the next day. He was tolerating oral food and fluids. Lab results were normal and he had no pneumonia or pathology. Venous Blood Gas (VBG) revealed mild compensated Respiratory Acidosis on the repeat VBG. 

The patient improved after treatment in emergency department.

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: Chest pain, shortness of breath. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a female patient with a history of coronary artery disease (CAD), transient heart block, hypertension, sleep apnea, brain tumor, recent coronavirus (COVID) infection, anxiety, and status/post (s/p) nephrectomy. She presented to the emergency room with a several day history of fatigue, shortness of breath, palpitations, and chest pain. Her vital signs were essentially normal. She was in no acute distress and did not appear toxic. The physical exam was normal. There were no intracranial abnormalities on a head computed tomography (CT) scan, and no active disease on the chest x-ray. Lab results were notable for a positive COVID ribonucleic acid (RNA) test. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. 
Upon admission to a monitored bed, the patient was treated with oral medications and continuous positive airway pressure (CPAP). The remainder of the stay was clinically uneventful and the patient was discharged. At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient admission was not medically necessary for this patient. Based on a review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, or severe metabolic disarray. The services provided, oral medications, CPAP, rule out protocol, were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 35 Hours a Week. The health plan's determination is upheld. 

This is a case review for a female with medical history notable for mobility issues, incontinence, arthritis, prior kidney transplant, paranoid personality disorder, and osteoporosis. The patient and her care team requested Consumer Directed Personal Assistance Services (CDPAS): 35 Hours a Week.

The requested Consumer Directed Personal Assistance Services (CDPAS): 35 Hours a Week are not medically necessary for this patient.
The patient requires some assistance with Instrumental activities of daily living (IADL). She requires limited assistance with a couple of activities of daily living (ADL), but is otherwise independent. The task tool recommends 16 hours per week to address her needs, which was approved by the health plan. The patient has consumer-directed hours and can redirect them as she sees fit to best address her needs. There is no documentation regarding which personal care needs, if any, are not being met with this level of personal care assistance. There is insufficient documentation regarding the medical necessity for the requested increase in personal care hours.