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

Diagnosis: Cough

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient was admitted to the hospital with complaints of a cough for a few weeks. The patient had recent travel to India. Past medical history was significant for coronary artery disease, diabetes and hypertension. Vital signs at presentation were: Temperature 97.9 degrees F (Fahrenheit), Respirations 18, and oxygen (O2) saturation 96 % (percent) on room air.

The patient was in no acute distress. Lung exam revealed bilateral wheezes. Heart sounds were normal. The patient was alert and oriented x 3. The patient was treated with Combivent and intravenous (IV)  Steroids.

White blood cells (WBC) were 9.5, Hemoglobin 12, respiratory viral panel including Covid was negative. The patient was admitted with a diagnosis of Asthma Exacerbation and was placed on Prednisone 40 milligrams (mg) per day X 5 days and Duo Nebs.

The patient was in no acute distress, and was afebrile with clear lungs.  Oxygen saturation was stable at 95% on room air.

This patient did not need acute inpatient hospitalization. The patient could have been placed in Observation status which could be for up to 48 hours while diagnostic testing and treatment were initiated. The patient remained stable after admission and was discharged the next day. Patient was afebrile and Hemodynamically stable. There was no hypoxia, no pneumonia or pleural effusion. The patient was ambulatory and tolerating food and fluids. Acute inpatient hospitalization was not necessary.

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 hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Racing heart
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male admitted with a sensation of heart racing. There was a history of hypertension, hyperlipidemia, and smoking. There was fatigue and some shortness of breath with exertion. He was started on a beta blocker as an outpatient with no improvement of his symptoms. The patient's vital signs were normal. He was in no distress. Troponins were minimally elevated. The electrocardiogram (ECG) demonstrated sinus bradycardia with sinus arrhythmia. Catheterization was negative for coronary artery disease (CAD). The left ventricular ejection 
fraction (LVEF) was normal. Electrolytes were normal. The patient remained stable and was discharged.

The proposed treatment was not medically necessary.

This patient presented with chest pain and remained stable. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident [CVA]), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or an acute coronary syndrome. 
In the setting of this case, an acute inpatient level hospitalization, compared to for example observation, has not been established as standard of care toward improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male with low back pain and history of multiple laminectomies and fusions in the past. The patient presented to the emergency department with severe pain. The patient required intravenous steroids, intravenous Dilaudid, and intravenous non-steroidal anti-inflammatory drugs (NSAIDs) and neurosurgery was consulted. The patient was admitted and the plan was for possible surgery. On hospital day 2, the patient was unable to tolerate magnetic resonance imaging (MRI). The patient left against medical advice.

The requested health service was medically necessary.

The patient had severe pain that required intravenous medications for pain as well as neurosurgery consultation. The patient was considered a possible neurosurgery candidate and the pain control as well as surgery evaluation could not be performed at a lower level of care. Therefore, the entire acute inpatient hospitalization was medically necessary and appropriate for the dates in question.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Bowel Problem (diverticulitis).
Treatment:  Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

This patient is an adult female who presented to the emergency room with progressively worsening constant, moderate, lower abdominal pain for five days. The patient presented to the emergency room and was discharged on day #3. The patient had gas-like cramping and constipation. The patient reported an inability to eat for five days secondary to the pain. The patient's white blood cell (WBC) count was 14.3. Computed tomography (CT) scan of the abdomen/pelvis showed severe diverticulitis in the left lower quadrant (LLQ) without perforation or abscess. In the emergency room, the patient was treated with intravenous Cipro 400mg (milligrams) x 1 (one time), intravenous Ketorolac 15mg (milligrams) x2 (two times), intravenous Morphine 4mg (milligrams) x1 (one time), intravenous fluids, and nothing by mouth (NPO). On day #2, the patient reported mild left lower quadrant pain. There were no overnight events. A regular diet was started, and the patient was reportedly tolerating her diet well and having regular bowel movements. Additionally, there were no fevers/chills. The request for coverage of the inpatient hospital admission is under review. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding, nor was there an evaluation requiring the patient to not eat or drink for an extended period (e.g., (for example) more than 24 hours). Additionally, the patient did not have an inability to maintain oral hydration (e.g. (for example), needs intravenous fluid support) that persists after observation care, and she did not have suspected toxic megacolon, nor bacteremia. Furthermore, the patient did not require a procedure that could not have been performed on an ambulatory basis. As such, the requested inpatient admission would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Carvajal Syndrome
Treatment: Stelara sub-q injection (ustekinumab)
The insurer denied Stelara sub-q injection (ustekinumab).
The health plan's determination is overturned. 

The patient is a male with Carvajal syndrome, a rare genetic syndrome characterized by a palmoplantar keratoderma (similar to psoriasis), woolly hair and cardiomyopathy. The provider has recommended Stelara. Prior treatments include topical steroids and topical keratolytics.
At issue is the medical necessity of Stelara subcutaneous (sub-q) injection (ustekinumab).

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

The requested health service/treatment of Stelara sub-q injection (ustekinumab) is medically necessary for this patient.
Stelara has been found to be effective in patients with mutations in the desmoplakin gene. T helper 1 and T helper 17/interleukin (IL) 23 skewing in the skin and T helper 17/interleukin 22 skewing in blood have been noted in these patients, and Stelara is an IL-23 inhibitor. This is a rare condition for which large, controlled trials are not possible. The patient has tried and failed appropriate therapies and Stelara is approved for this age group. Stelara has also been shown to be effective in other genetic ichthyoses. Therefore, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a pregnant female who presented with left flank pain at 28 weeks gestation. She was provided intravenous hydration. A Renal ultrasound showed mild nephrosis and her urinalysis showed moderate blood, large leukocytes and bacteria with white blood cells. Urine culture was negative. She was diagnosed with renal colic. Pain medication was administered. Under review is the inpatient level of care. 

Inpatient Hospital Admission was not medically necessary for this patient. 
The patient was a healthy female without significant comorbidities. She had flank pain and pain medication with hydration was provided. This could have been performed at a lower level of care. The patient could have also been monitored by her clinic as well. She had no rupture of membranes, preterm labor, or vaginal bleeding. Her vital signs were normal and she had no hemodynamic instability. She had no pulmonary complications nor hepatic complications. Urine culture, ultrasound and studies were negative. There was no need for an acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: amplified pain syndrome
Treatment: Inpatient rehab
The insurer denied inpatient rehab treatment. The health plan's determination is upheld.

The patient is a female with a history of amplified pain syndrome. She also has a history of obsessive-compulsive disorder (OCD), depression and post-traumatic stress disorder (PTSD). The records indicate that she has been seen weekly for psychotherapy services and was taking Lexapro. Her treating provider recommended an inpatient pain rehabilitation program with comprehensive physical therapy, occupational therapy and psychological counseling.

The inpatient rehabilitation stay is not medically necessary.
Inpatient rehabilitation may be provided in a hospital, a free-standing facility or skilled nursing facility. The setting for inpatient rehabilitation is principally determined by the individual's medical and functional status and the ability of the rehabilitation facility to provide the necessary level of care. Acute inpatient rehabilitation is required when an individual's medical status is such that the intensity of services required could not reasonably be provided in an alternative setting (subacute facility or outpatient rehabilitation department). Examples of conditions requiring acute inpatient rehabilitation include, but are not limited to, individuals with significant functional disabilities associated with stroke, spinal cord injuries, acquired brain injuries, major trauma and burns. The patient should be able to tolerate 3 hours of therapy per day for 15 hours a week and require physician evaluation 3 times a week. However, in this case there is no indication that the patient requires face to face monitoring with a physician 3 times per week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other- Fever
Treatment: Full hospital admission 
The health plan denied: Full hospital admission
The determination is: Upheld

The patient is a female who presented to the emergency room with a headache that had been present over the prior three weeks and was refractory to Tylenol and Motrin. She was initially afebrile, and her exam was unremarkable. Her vital signs were within normal limits and the imaging studies of her brain were unremarkable. Her laboratory studies revealed pancytopenia, and she was admitted for neutropenic fever and sepsis.
The patient was evaluated by hematology and underwent a bone marrow examination. She received intravenous (IV) antibiotics and 1 unit of packed red blood cells.
At issue is the medical necessity of the full hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of full inpatient hospital stay was not medically necessary for this patient. The patient was admitted with pancytopenia including a non-absolute neutropenia. She had no clinical evidence of infection and received only supportive care during her hospitalization. The services rendered during her stay included laboratory studies, transfusion of blood products, and a bone marrow examination, none of which required an inpatient level of care. Her remaining services were primarily supportive in nature. Not only were Milliman Care Guidelines (MCG) criteria not satisfied, but support in the literature for the inpatient level of care for this patient is not present, and thus, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite/Underbite
Treatment: Insertion of Braces and Adjustment of Braces

The health plan denied: Insertion of Braces and Adjustment of Braces

The determination is: Upheld

The patient is a male with a Class I occlusion. He has a 5 millimeter (mm) overbite and a 1mm overjet. He has minor maxillary and mandibular crowding. He is in the late mixed dentition stage of dental development with five remaining primary teeth, and his second molars are still far from eruption. The patient is treatment planned for orthodontics to correct his malocclusion, but his insurance company rejected the claim on the basis that treatment is not medically necessary.
At issue is the medical necessity of the insertion and adjustment of braces.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of the Insertion of Braces and Adjustment of Braces is not medically necessary for this patient.
There is currently no medical reason to correct his malocclusion with braces. The patient has crowding, but none of his teeth are impacted. His overbite is deep, but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the upper incisors in occlusion, not the palate. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present. There are some functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion.[2] The patient does have a slightly excessive overjet, but this amount of overjet does not negatively affect oral health related quality of life. If his teeth were aligned it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. Therefore, orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypopituitarism. 
Treatment: Skytrofa. 

The insurer denied Skytrofa. 
The determination is upheld. 

This is a male patient diagnosed with hypopituitarism. This request is for Skytrofa. He is on Nutropin 1.3 milligrams (mg) per day (0.22 milligrams/kilogram/week (mg/kg/wk)). His growth hormone (GH) stimulation test peaked at 7.1. He also has attention deficit hyperactivity disorder (ADHD). At issue is the medical necessity of Skytrofa. 

The requested treatment Skytrofa is not medically necessary for this patient.
The requested medication has been shown to be safe and effective for the treatment of growth hormone deficiency (1,2). The study using the medication shows that the medication is clinically equivalent to daily injections of growth hormone in terms of efficacy and safety. The study showed a slight advantage of the Skytrofa over daily somatropin but only went for 1 year and did not show improved final height. It has the advantage of being a weekly medication. Other than the convenience of weekly administration, the requested medication is not superior to daily growth hormone.
The patient does not show documentation of a trial and failure of the formulary alternatives, Nutropin or Humatrope. The patient is on Nutropin without documentation of failure. The patient can try the formulary alternatives. The requested Skytrofa is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental delays
Treatment: Durable Medical Equipment (cubby plus safety bed- E1399)
The insurer denied: Durable Medical Equipment (cubby plus safety bed- E1399)
The denial is overturned.

The patient is a school age female with a history of developmental delays and autism spectrum disorder. The child exhibits maladaptive behaviors as well as sensory processing disorder. Medical records report bed elopements, falling out of bed, and disrupted sleep wake cycle. A specialty cubby bed has been requested by the treating healthcare provider following a well-documented trial of alternatives. The health plan denied coverage of the specialty bed due to lack of medical necessity. 
The denial is being appealed.

The requested cubby plus safety bed is medically necessary.

In this case, the child has been diagnosed with cognitive impairments and severe behavioral disorder requiring medication management. She has a well-documented high risk of falls with 
uncontrolled movements. All of the above meet criteria for medical necessity for beds with safety enclosures. Therefore, the requested cubby plus safety bed is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Skilled Nursing Facility

Diagnosis: total hip replacement
Treatment: Skilled Facility Care
The insurer denied Continued Skilled Nursing Facility (SNF) Care. The health plan's determination is upheld. 

The patient is a female with a past medical history (PMH) of R (right) THR (total hip replacement) and revision surgery after which she was discharged to Skilled Nursing Facility (SNF). She was to be non-weight bearing (NWB) x 2 weeks followed by TTW (toe touch weight) in abduction brace after that. According to her last physical therapy (PT) evaluation at the SNF provided, she remained NWB to her right lower extremity (RLE). The maximum distance she ambulated was 5 feet with a RW (rolling walker) with a hopping gait. The PT (physical therapist) noted that she was making progress toward her goals. She did not have any medical complications post operatively.
She was evaluated post-operatively - the most recent note recommended partial weight bearing (PWB), ongoing PT, to consider titrating off narcotics and medical management of her intermittent bilateral lower extremity edema.

Continued Skilled Nursing Facility (SNF) Care is not medically necessary for this patient.
Based on the documentation provided, the patient has ongoing physical therapy and rehabilitation needs; however, there was no documentation provided of ongoing nursing needs such as IV medications or surgical site care. Therefore, continued skilled nursing facility care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Deteriorating cognitive and physical abilities
Treatment: Home Care / Personal Care HHC-Level 2 Personal Care services, per 15 minutes increase to 84 hours per week
The insurer denied Home Care / Personal Care HHC-Level 2 Personal Care services, per 15 minutes increase to 84 hours per week.
The health plan's determination is overturned.

This is a female patient who has Alzheimer's disease with progressive amnesia, frequent episodes of disorientation, agitation, anxiety and emotional lability. She is described as having rapidly deteriorating cognitive and physical abilities. 
It is the request of her primary care physician that with her rapidly declining physical and cognitive state in addition to her functional and sensory limitations an increase in services be provided.
It is her physician's assertion that she is no longer able to independently perform tasks such as cooking, cleaning, bathing, dressing, grocery shopping or maintaining her household in addition to other general daily tasks. She requires daily assistance with medications and meal preparation. The last Uniform Assessment System (UAS) was done prior to husband's death. The reported accelerated decline was subsequent to this. Per the UAS, the patient was instructed to void every 2 hours and limit fluid intake in the evenings to decrease incontinence episodes. This appears problematic when she only receives 3 hours of care a day and is totally dependent with diaper changes. 
At issue is the medical necessity of Home Care / Personal Care HHC-Level 2 Personal Care services, per 15 minutes increase to 84 hours per week.

The patient has advancing needs and requirements in various activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) as outlined in the physician's note/request. As documented in the note from her physician, the patient's situation and circumstances changed from her last assessment. With her various medical conditions and care needs, her dependency on others has been further manifested with the passing of her husband. There has been a loss of support with his passing. Further, this has accelerated her physical, mental and emotional decline.
The patient's various and multiple medical/physical needs necessitate the the requested services for the requested duration. 
The requested services 84 hours/week is medically appropriate.