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

Diagnosis: Diabetes
Treatment: Nursing Services (including Private Duty Nursing)

The patient is a male with a past medical history significant for dementia, depression, chronic kidney disease, hypertension, and diabetes mellitus type 2. There are noted cognitive changes secondary to dementia. A letter from the patient's physician states that the patient is unable to ambulate in his home without assistance. He has been approved for 56 hours a week. This review is from the medical necessity of consumer directed personal care assistant services, 75 hours per week. 

The health plan's determination is upheld. The Consumer and Self-Directed Personal Assistance Services: 75 Hours per week is not medically necessary for this patient. The patient is a male with multiple medical problems most notably advancing age, dementia cognitive dysfunction and ambulatory dysfunction. However, the services already being provided are adequate to meet the patient's medical needs. There are no noted services that cannot be met within the allotted time. The Uniform Assessment System (UAS) State of New York notes the following: the patient requires services for most IADLs and many ADLs. There have been no recent falls within the last 90 days as well as no hospitalizations within the last 90 days. It is noted that the patient does not walk on his own and uses pull-ups for incontinence care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of morbid obesity, atrial flutter, pulmonary embolus and chronic leg edema, tobacco use, and alcohol abuse (5-10 beers 5 days a week).  He presented to the emergency room (ER) with increased dyspnea over a few weeks.  On the evening of admission, he developed diffuse chest pain.

The patient's blood pressure (BP) was 132/60 millimeters of mercury (mmHg) with a pulse of 121 beats per minute (bpm), a respiratory rate of 22/minute, and a temperature of 36.7 degrees Celsius (C).  The exam was significant for clear lungs, 2+ pitting edema of the abdomen and lower extremities bilaterally.  A computed tomography (CT) angiogram done in the ER was negative for pulmonary embolus, but showed an inflamed gallbladder, likely cholecystitis.  The troponin was negative, Pro brain (or B-type) natriuretic peptide (BNP) was 320, with a white blood cell count (WBC) of 4820, platelets of 42, 000, and a hemoglobin of 8.8.  Liver function tests were elevated with a total bilirubin of 5.9, a serum glutamic-oxaloacetic transaminase (SGOT) of 86, and an alkaline phosphatase of 146.  He was admitted to rule out cholecystitis.  An ultrasound was done showing no visualization of the gallbladder, due to the patient's body habitus.  Clinical correlation was recommended.  A venous duplex of the legs showed no deep vein thrombosis (DVT).

He was given intravenous Lasix for edema and intravenous antibiotics for possible cholecystitis.  Surgical and gastroenterology (GI) consults were obtained.  The surgical consultant reviewed imaging and determined that no gallstones were seen on CT scan and, as the patient had no symptoms related to a biliary pathology, that diet be given as tolerated and no surgical intervention performed.  The GI consult was obtained and recommended discontinuation of alcohol use, hepatitis serology and transfusions as needed (prn).  His elevated liver function tests, anemia, and low platelets were felt possibly due to alcoholic liver disease.  A pulmonary consult was obtained to rule out obstructive sleep apnea.  Outpatient pulmonary function tests and sleep study were recommended.  An echocardiogram (ECHO) was done showing normal left ventricular (LV) systolic function.  The study was technically limited.  The patient signed out against medical advice (AMA).

At issue is the medical necessity of the inpatient stay.  The health plan's determination is upheld.

The patient has multiple chronic medical issues, including morbid obesity, alcohol abuse, a history of pulmonary emboli and chronic edema.  He presented with chest pain but did not have objective evidence for an acute coronary syndrome.  He had abnormal findings on an abdominal CT scan, suggesting acute cholecystitis.  However, there were no exam findings or lab findings confirming the diagnosis, and a surgical evaluation indicated no acute cholecystitis.  The remainder of his workup for liver disease, possibly alcohol-induced, anemia, thrombocytopenia, and sleep apnea could have been done at a lower level of care.  Inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient stay

The patient is a female with multiple risk factors and known coronary artery disease who presented for elective catheterization in the setting of angina, and abnormal stress test and residual disease of the right coronary artery. She underwent percutaneous coronary intervention (PCI) of the mid right coronary artery (RCA) but the distal RCA chronic total occlusion (CTO) could not be treated successfully. She was admitted for monitoring and discharged the following day without event.

The health plan's determination is upheld. The inpatient stay is under review. This was an elective, although complex, procedure. Despite the PCI being unsuccessful, there were no significant complications. The care of this patient could have been appropriately and safely carried out at a lower level of care which includes an overnight stay. There were no clinical, hemodynamic, vascular, electrocardiographic, laboratory, procedural or postprocedural issues that warranted an inpatient level of stay. There were no features unique to this elective and uncomplicated procedure that warrant a higher level or stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 

The patient is a female presenting with a skeletal Class II malocclusion and minor crowding. She has an anterior open bite, and a significant (8+ millimeter [mm]) overjet. She is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 20, and 29 to address the crowding and open bite. At issue is the medical necessity of the requested health service/treatment of braces. 

The health plan's determination is overturned. 

Orthodontic treatment is medically necessary for this patient due both the anterior open bite and the excessive overjet and protrusion of the maxillary incisors. 
Anterior open bite patients are among the most difficult patients to treat.[1] One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.[2] Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite.[3] This patient is treatment planned for extractions, which is less invasive than orthognathic surgery. 
Furthermore, there is strong medical evidence that that correction of patients with prominent maxillary front teeth like the patient has can reduce the risk of incisor trauma.[4] Extraction of four premolars combined with orthodontics will make her teeth less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Home Health Care 

The patient has a past medical history significant for hypertension, hyperlipidemia, coronary artery disease, pancreatic insufficiency and gastroesophageal reflux disease. 
The patient was previously receiving 20 hours a week of services; however, the services were decreased to 16 hours a week. 

The request is for health service/treatment of reinstatement to 20 hours per week of CDPAS (consumer directed personal assistance services). 

The health plan determination is upheld in whole. 

The requested service of CDPAS reinstatement 20 hours per week is not medically necessary. The patient was receiving 20 hours a week of consumer directed personal care service which were decreased to 16 hours a week.  A home assessment recommended that the patient have 12 hours per week. The patient is currently having 16 hours per week. 

It is noted that the patient is alert and oriented and can direct own care. The patient can toilet independently and can manage personal hygiene independently. The patient can dress the lower body with some help. The patient can ambulate without a cane. There are no noted recent falls. It was noted the patient could walk between 150 and 299 feet. The patient does live with family. The family can help with instrumental activities of daily living (IADLs) including grocery shopping and cleaning. The patient is noted to have intermittent urinary incontinence but no bowel incontinence, and uses incontinent supplies such as adult diapers. 

The Uniform Assessment System (UAS) summary noted most of the services included Level One services including meal preparation and housework and shopping. Level 2 services were noted. The patient did require help with bathing and dressing lower extremity. A previous evaluation for certification noted that the patient required a total of 7.3 hours a week. 

According to the documentation reviewed additional service hours are not medically necessary. The requested services hours of 20 hours per week are in excess of the documented need. Documented need is 12 hours per week. Patient is scheduled for 16 hours a week which is enough to meet the amount of services required. 

It is reasonable to expect that the amount of services noted to be medically necessary can be performed in the allotted time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: possible new onset of seizure versus syncope versus vs hypokalemia

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a male who presented to the Emergency Department (ED) from an Urgent Care facility due to an abnormal electrocardiogram.  The documentation indicated that the patient was in his bedroom when he fell out of bed hitting his head against a side table.  The patient eventually got up and told his family later that he had fallen, and he was taken to the urgent care facility where he was told to present to the Emergency Department.  The patient denied dizziness, changes to vision, focal weakness or numbness.  The patient's past medical history included hyperlipidemia and hypertension.  The patient's vitals revealed a heart rate of 67 bpm, blood pressure of 127/74, and 97% oxygen saturation on room air. On exam, the patient was alert and oriented, and had normal sensation to all of his four extremities. The patient's laboratory studies did not reveal any significant abnormalities. The documentation indicated that the patient should be admitted for possible new onset of seizure versus syncope versus hypokalemia. While admitted in the hospital, the patient had no significant adverse events.  There were no further significant abnormalities found, and the patient did not have any further clinical decline.  The patient was discharged the following day with instruction to follow-up as outpatient.

Based on the review of the medical records, there is no clear evidence of an acute change in the patient's neurological examination or imaging that required inpatient level of care. Based on the literature review, clinical indications for inpatient admission include new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure. However, this patient neither had any motor/sensory deficits nor abnormal testing (i.e. CT scan of the head, EKG of the heart, chest x-ray) that indicated that this patient had an acute stroke or need for inpatient workup. The patient's hospital course was unremarkable, without any new episode of loss of consciousness, and the patient was discharged in stable condition the following day of admission. 

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

The carrier's denial of coverage for the inpatient admission is not upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Appendicitis
Inpatient Hospital

This patient is a previously healthy female who presented to the emergency room  with abdominal pain, nausea, vomiting, and diarrhea. Her vital signs were normal at presentation. She was tender in the upper left abdomen. She was evaluated with labs that showed a normal white blood cell count (WBC) count and normal liver function studies. An ultrasound revealed cholelithiasis, gallbladder wall thickening, and pericholecystic fluid. She was admitted to the hospital and was initially treated with nothing by mouth (NPO) status, intravenous (IV) fluids and antibiotics. The patient underwent a laparoscopic cholecystectomy. The anesthetic record does not indicate any intra-operative abnormality during the operation. The operative dictation describes normal intraoperative conduct. She was started on a liquid diet following surgery.  Vital signs were normal. She was reported to be doing well post-surgery.  She was afebrile with normal vital signs. The diet was advanced, and she was considered stable for discharge home.

The patient was hemodynamically stable, there was no vomiting, signs of infection, bleeding or excessive pain after surgery. Nor did the patient have underlying health problems that would require an inpatient level of care.

At issue is the medical necessity of the inpatient stay.

The health plan's determination is upheld. 

The records do not support the medical necessity of inpatient admission for this patient. The care and treatment provided could have reasonably and safely been provided at a lower level of care during this time. Her evaluation with ultrasound confirmed the diagnosis of cholecystitis. The patient underwent uncomplicated laparoscopic cholecystectomy. Inpatient admission was not medically necessary for this patient as she was afebrile with stable vital signs and was tolerating a diet. The treatment provided could have been rendered at a lower level of care. This would permit appropriate resources for preoperative evaluation, surgical care and post-operative monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Kidney disorder: Other 
Treatment: Inpatient hospital 

This is the case of a male with past medical history of depression and attention deficit disorder who presented to the emergency department with thigh pain, difficulty moving his legs, and dark urine. 

On presentation, he was noted to be afebrile with blood pressure 149/88, heart rate 85, respiratory rate 16, and oxygen saturation of 100% on room air. Exam otherwise noted dark urine. Labs showed white blood cell (WBC) 8.8, Hemoglobin (HGB) 15.4, Platelets 142, NA (sodium)139, K (potassium) 4.5, bicarbonate 28, blood urea nitrogen (BUN) 18, creatinine 1.2, creatinine kinase of 13,376, myoglobin of >4000. The patient was given intravenous (IV) fluids in the emergency department and subsequently brought into the hospital with concern for rhabdomyolysis. 

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient presented with severe rhabdomyolysis with creatinine kinase increasing to 115,442 with concomitant acute kidney injury and rise in creatinine to 1.6 was at high risk for worsening acute kidney injury, acidosis, and frank kidney failure. He required several days of aggressive high-volume IV hydration with isotonic fluids in addition to bicarbonate infusion for renal protection with close basic metabolic panel (BMP) monitoring that could not be safely performed in the outpatient setting and could not be stopped until his creatinine kinase was noted to be decreasing. Inpatient stay was medically necessary for this patient with severe rhabdomyolysis with concomitant acute kidney injury that worsened after presentation requiring aggressive IV hydration, bicarbonate infusion, close BMP monitoring who was at risk of acidosis, hyperkalemia, and frank renal failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The proposed inpatient stay for uncomplicated appendicitis was not medically necessary. 

The patient is a male with three days of abdominal pain without fever, nausea, vomiting or diarrhea. Emergency department (ED) evaluation revealed periumbilical and right lower quadrant (RLQ) tenderness, white blood cell (WBC) count 11K, and a computed tomography (CT) scan consistent with appendicitis and no perforation. The patient was taken to surgery and underwent a laparoscopic appendectomy. The base of the appendix was inflamed without any evidence of necrosis, gangrene, or perforation. The patient was admitted overnight and discharged the following morning tolerating a diet, ambulating, and no evidence of fever. 

The patient presented with uncomplicated acute appendicitis without any evidence of sepsis, hemodynamic instability or compromise. 

After either open or laparoscopic appendectomy for nonperforated appendicitis, patients may be started on a clear liquid diet and advanced as tolerated to a regular diet. Antibiotics are not required postoperatively. Most patients are discharged within 24 to 48 hours of surgery. Same-day discharge is feasible, most commonly following a laparoscopic appendectomy. The records support that this patient could have been treated at a lower level of care due to uncomplicated appendectomy and hemodynamic stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain, leg pain, incontinence 
Treatment: Inpatient admission 

The inpatient admission was medically necessary. 

The patient is a male with history of multiple medical problems, including back pain. The patient had T10-11 laminectomy and fusion. The patient was brought back to the ED with low back pain and leg pain with incontinence. 

The patient was admitted at that time with difficulty ambulating and hypertension requiring IV morphine and neurosurgery consultation. 

The patient was placed in observation and an MRI was performed to rule out urgent issue requiring surgery. The patient was also evaluated by PT (physical therapy). The patient was cleared and discharged that same day. 

The patient was provided severe pain IV opioids, and this must be provided as an acute inpatient level of care. This would not be appropriate at a lower level of care, and the patient did require neurosurgery and PT inpatient consultations as well as MRI. These requirements, in addition to the IV pain medications, and close neuromonitoring supports acute level of inpatient care for the days in question. All days would be considered medically necessary and appropriate for this patient. 

Based upon the patient's clinical presentation, severe pain, and concerning history, acute inpatient care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Pulmonary embolism

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a female patient who was status post left foot injury resulting in a left foot sprain and small avulsion injury. She presented to the Emergency Department (ED) with complaints of leg swelling. She had a chest x-ray that revealed mild bi-basilar plate like atelectasis. An electrocardiogram was performed that showed sinus tachycardia. An ultrasound of the lower extremity was performed that showed a deep venous thrombosis (DVT) of the left superficial femoral vein, popliteal vein and calf vein. A computed tomography (CT) scan of the chest was done revealing bilateral pulmonary embolism. The patient was started on an intravenous (IV) Heparin drip for treatment of her DVT and pulmonary embolism and was later transitioned to oral Eliquis. She developed a fever; her work up was negative for a bacterial infection. It was determined that she had a viral upper respiratory infection that was treated with Tylenol. The patient was hemodynamically stable and discharged home.  

Based on the review of the medical record, this patient did not need acute inpatient hospitalization. The patient had pulmonary embolism but was hemodynamically stable. There was no evidence of right heart strain or hemodynamic instability or significant hypoxia. Patient had no contraindication to anticoagulation.

This patient could have been placed in an observation setting while diagnostic testing and treatment for pulmonary embolism were initiated, and be discharged on oral Eliquis.

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 inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient is a male. The patient presented with a frontal headache and abdominal pain. Blood glucose was found to be 607. The patient was taken to the emergency room. The patient had a history of polyuria and polydipsia for several weeks. The patient has a family history of type I diabetes and brother and sister. 

In the emergency room, the patient had a glucose of 479. He was ketone positive. He was given intravenous normal saline boluses. The patient was diagnosed with new onset type I diabetes. He was started on Levemir and NovoLog using an insulin to carbohydrate ratio and an insulin sensitivity factor. Hemoglobin A1C (glycated hemoglobin) was found to be 11.1%. The patient received new onset diabetes education. 

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components [1, 2]. 

Practice patterns differ depending on the availability of educators etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the US [3] that treat new onset type 1 diabetes admit their patients. According to the ADA statement on treatment of type 1 diabetes [4], hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  That is not the case for type 2 diabetes. Indications for admission for new onset type 2 diabetes are more stringent and dependent upon the presence of symptoms such as ketosis, dehydration, hyperosmolarity, vomiting and inability to maintain hydration or severe metabolic/electrolyte abnormalities.  

In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a two to three day admission to the hospital [5-8]. 

This patient had new onset type I diabetes and required all aspects of diabetes education in addition to determination of his insulin regimen. The patient is of an age where he should learn how to self-inject and check blood glucose. The duration of the admission was appropriate for complete diabetes education. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.