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

Diagnosis: Typical atrioventricular (AV) node reentry tachycardia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is the case of a male patient with a history of palpitations that presented to the hospital for an elective electrophysiologic study with possible ablation. Typical atrioventricular (AV) node reentry tachycardia was diagnosed and successfully treated during his procedure. Post-procedure, the patient was noted to have a systolic blood pressure (BP) in the high 80-90 millimeters of mercury (mmHg) range without symptoms. He was treated with intravenous (IV) fluids and metoprolol therapy was held. Exam was benign and right groin access site was without hematoma or ecchymosis. The patient was discharged without further intervention the following day.  

This patient presented for elective electrophysiology study (EPS) with ablation. He had a successful slow pathway modification without complication and was discharged the following day. Several studies have demonstrated both feasibility and safety of same day home discharge following radiofrequency ablation. In one study, a cohort of over 1300 individuals undergoing catheter ablation were discharged on the day of their procedures following a six hour observation period. (1) The authors of this study concluded that more than 90% (percent) of patients presenting for elective EPS with ablation could be discharged the same day. In a second study of 11,000 patients undergoing catheter ablation of accessory pathways, the median length of stay following ablation was one day. (2)

In this case, a successful and uncomplicated slow pathway modification was performed. The patient was observed overnight and discharged the following morning. Inpatient hospital admission was not medically necessary. This patient could have been treated at a lower level of care.  

The healthcare plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Alzheimer's dementia, hypertension, gout, gait instability and history of recurrent falls
Treatment: Personal Care Aide Level 2: 8 hours per day - 5 day(s) per week for a total of 40 hours per week
The insurer denied the Personal Care Aide Level 2: 8 hours per day - 5 day(s) per week for a total of 40 hours per week
The denial is overturned. 

The patient is a male with a history of Alzheimer's dementia, hypertension, gout, gait instability and history of recurrent falls. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 40 hours/week Personal Care Aide to offer increased ADL (activities of daily living) support.

Yes, the requested increase in personal care aide services to 40 hours per week is medically necessary.
The patient is a male with a history of Alzheimer's dementia, hypertension, gout, gait instability and history of recurrent falls. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and noted that 20 hours/week personal care aide is sufficient; the patient's provider reports that this reduced schedule leaves the patient home alone, completely unassisted for numerous hours/day. This is problematic, as the patient requires assistance with dressing, bathing and meal preparation.

Hence, provision of 40 hours/week Personal Assistance Services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 40 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Precocious Puberty

Treatment Fensolvi

The insurer denied coverage for Fensolvi

The denial is overturned

The definition of precocious puberty is children who have the onset of secondary sexual characteristics at a very young age [1-3]. Central precocious puberty (CPP) is diagnosed using a basal lutenizing hormone (LH) of >0.3 or stimulation testing with a gonadotropin releasing hormone (GnRH) analog such as leuprolide showing a pubertal response defined as an LH >10[4]. CPP is treated with GnRH agonists [5-10] such as Lupron [11] Fensolvi and Supprelin [12]. The FDA [food and drug administration] indication for GnRH agonists is for use in central precocious puberty (CPP). In addition, when used for CPP the Food and Drug Administration (FDA) recommends discontinuation of GnRH agonists before teenage years [11]. This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone age of preteen. [2, 4-7]. 

The patient has onset of breast development at an early age and an LH that is in the pubertal range. An advanced bone age is not part of the criteria for the diagnosis of precocious puberty. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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

The insurer's denial of coverage for Fensolvi for the treatment of central precocious puberty is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pain related to metastatic disorder

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of stage 4 lung cancer with metastasis to the abdomen, adrenal cancer, renal cancer status post left nephrectomy and radiation, hypertension, pulmonary embolism.

Milliman Care Guidelines (MCG) clinical indications for admission for undiagnosed abdominal pain (M-05) include hemodynamic instability, severe pain that cannot be controlled, inability to maintain oral hydration, bacteremia and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

The patient had different pains related to extensive metastatic disorder. He was still having pain on his home regimen. He required a palliative care consult and the pain control medication needed to be increased. However, the increased narcotic dose could have been given as an outpatient. The pain improved when the new regimen was started. He did not meet MCG criteria for admission for undiagnosed abdominal pain. The healthcare plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessity. 

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

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

Diagnosis: Venous Ulceration.
Treatment: Topical Hyperbaric Oxygen Chamber.

The insurer denied the Topical Hyperbaric Oxygen Chamber.  The denial is upheld.

The patient is an adult male, who caught his left foot in the spoke of a bike.  The patient was treated in the emergency department with primary closure and a posterior splint. He was advised to avoid bearing weight and use crutches. He was treated with oral antibiotics, as well.

The patient was evaluated by a podiatric surgeon and noted to have intact sutures without dehiscence of the left ankle.  He was advised to avoid bearing weight and use crutches.

A progress note a month later indicated there was an ulcer in the patient's left ankle measuring 1x3 x.4 cm (centimeters) after sutures were removed. There was necrotic tissue noted under a skin flap.  The wound was debrided with a podiatric surgeon and an antimicrobial dressing was applied.  Topical Oxygen was recommended for assisting in wound closure.

Subsequently, one month later, the patient underwent application of a PRP (platelet-rich plasma) disc/Fibrinet with delayed primary closure to the left heel.

No, the Topical Hyperbaric Oxygen Chamber is not medically necessary.

There is insufficient evidence demonstrating the advantage of topical oxygen for traumatic wounds in healthy patients.  The studies referenced in the records (Ref 1, 2) and the case studies provided show the benefit of topical oxygen for diabetic foot ulcers and immunocompromised patients.  The injured patient, in this case, does not have diabetes.  There is also no indication that the patient has failed debridement or application of the PRP (platelet-rich plasma) disc.  A such, the Topical Hyperbaric Oxygen Chamber is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver Disease, Abdominal Pain, and Leg Swelling. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

This is a male with a past medical history alcohol (ETOH) abuse, cirrhosis, hepatic encephalopathy on lactulose and rifaximin, gastrointestinal bleed (GIB), and anemia requiring transfusions, who presented to the emergency department with abdominal distention and leg swelling.  He has a history of alcohol induced cirrhosis. 

The patient was admitted for anasarca, ascites, and anemia.  His hemoglobin was 6.5.  In the emergency department, the patient received intravenous Lasix.  Day two, the plan was to do an esophagogastroduodenoscopy (EGD) after large volume paracentesis.  The patient had paracentesis with removal of six liters of fluid.  He was given albumin.  He received one unit of packed red blood cells (pRBCs).  On day three, the patient underwent esophagogastroduodenoscopy (EGD) which showed portal hypertensive gastropathy.  He was given intravenous iron.  He was treated with ciprofloxacin.  He was evaluated for transjugular intrahepatic portosystemic shunt (TIPS) by hepatology but this was deferred.  On day six, the patient had another paracentesis with removal of four liters.  He had magnetic resonance image (MRI) of the liver which showed cirrhosis. 

Yes, the proposed treatment was medically necessary. 

Inpatient admission was medically necessary based on this patient's history of alcohol induced cirrhosis and underlying ascites (difficult to control) requiring intravenous Lasix and paracentesis times two.  Additionally, the patient had anemia (severe, with hemoglobin of 6.5) requiring esophagogastroduodenoscopy (EGD) to rule out acute gastrointestinal bleeding and requiring a blood transfusion and intravenous iron.  The patient required evaluation by Hepatology and was considered for the transjugular intrahepatic portosystemic shunt (TIPS) procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: aphasia and cognitive communication deficits.

Treatment: ten (10) additional speech therapy visits.

The insurer is denied coverage for ten (10) additional speech therapy visits.

The denial is upheld. 

This female patient has a history of anaplastic oligodendroglioma, status post craniotomy and chemotherapy.

The provided documentation does not support the need for 10 additional speech therapy sessions. A review of all documentation indicates that the patient has been receiving therapy since the start of care and has met most of her goals. The request for additional therapy is to help her generalize these skills. There is no data to show that additional therapy will result in significant functional changes in a reasonable and predictable period. There is no updated evaluation data to track progress since the start of therapy on standardized tests and no data to show that the patient continues to present with functionally significant deficits in the areas being targeted. The patient has learned to use the taught strategies to help her monitor her cognitive and emotional skills and to use the strategies to help her with word retrieval, attention, and memory. There is no data to support the need for ongoing skilled intervention. Ten (10) additional speech therapy visits are not considered medically necessary for this patient.

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

The carrier's denial of coverage for the ten (10) additional speech therapy visits is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis, ascites, and decompensated liver cirrhosis. 

Treatment: Inpatient level of care. 

The insurer denied coverage for the inpatient level of care. 

The denial is overturned. 

This is a male patient with history of alcohol abuse and cirrhosis. The patient was on vacation when he was diagnosed with cholecystitis and opted to wait for surgery until he returned home. When he returned, he had elevated bilirubin and was told to go to the Emergency Department (ED). The patient was admitted to the hospital for ascites and decompensated liver cirrhosis. 

Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation and is usually related to gallstone disease. Acute cholecystitis can be suspected with right upper quadrant or epigastric pain, fever, and a leukocytosis supported by a positive Murphy's sign. The history, physical examination, and laboratory test findings are not sufficient to make the diagnosis. Confirmation of the diagnosis requires demonstration of gallbladder wall thickening or edema, a sonographic Murphy's sign, or failure of the gallbladder to fill during cholescintigraphy. Acute cholecystitis must be distinguished from the more benign condition of biliary colic, which presents with the same type of pain. Most patients who develop acute cholecystitis have had previous attacks of biliary colic. Left untreated, symptoms of cholecystitis may abate within 7 to 10 days. However, complications are common, so patients with suspected acute cholecystitis require definitive treatment. The most common complication of acute cholecystitis is the development of gallbladder gangrene (up to 20 percent of cases) with subsequent perforation (2 percent of cases).

The admission was medically necessary at the acute inpatient level of care. The patient could not have been safely and effectively managed at an observational level of care or been directly discharged from the ED or ambulatory surgery unit based on the advanced age, comorbidity, and/or presenting complaints. Because of this patient's age and/or multiple comorbidities, and/or recurrent chronic symptoms, the review warranted the level of admission based on one week of abdominal pain and distention in a known alcoholic cirrhotic, on diuretics with jaundice noted.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. The inpatient admission was medically necessary. 

The insurer's denial of coverage for the inpatient level of care is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This patient is a male who presented to the emergency department (ED) with the complaint of abdominal pain. Comorbid health conditions included hypertension and he was reported to be COVID positive.  Vital signs at the time of presentation included an elevated heart rate of 120 beats per minute.  Examination revealed a tender abdomen in the right lower quadrant. The white blood cell (WBC) count was elevated at 12.1 thousand (K).  Abdominal computed tomography (CT) showed thickening of the cecum and proximal appendix.  Surgical consultation was obtained.  The patient was admitted to the hospital.

The patient was treated with nothing by mouth (NPO) status, intravenous (IV) fluid and antibiotics.  On day two, the abdominal pain was improved and the diet was advanced.  Vital signs were normal (heart rate was 82 beats per minute).  The patient was discharged from the hospital on day two with instructions for continued oral antibiotics and short term surgical follow up.

No, the proposed inpatient admission was not medically necessary.
In this case, inpatient care was not medically necessary.  The care and treatment provided during this time could have been rendered with an observation level of care and did not require an inpatient designation.  This lower level of care would have provided for surgical assessment and follow up, lab and imaging, and arrangements for outpatient follow up.

The health plan rationale for denial of inpatient care was based on Milliman Care Guidelines (MCG) Criteria-Medical.

Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored with an observational status.  

This patient presented with abdominal pain.  His evaluation with examination, lab data, and computed tomography (CT) scan identified cecal inflammation possible appendicitis.  The patient was treated with non-operative therapy (antibiotics, follow up labs, nothing by mouth [NPO] status) with clinical improvement overnight.  He did not require acute surgical intervention.  He was clinically stable during the period of monitoring and was able to be discharged with arrangements for outpatient follow up. 

This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for clinical assessment and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female. She presented to the emergency department with the complaints of abdominal pain, emesis and a decrease in oral intake for the preceding two days. The patient had a history of sarcoidosis, colitis, and a history of surgery for intussuception and cholecystectomy. The patient was a marijuana user.

The patient had abdominal tenderness on examination. The patient was reported as agitated. She received pain medication and supportive care. Once deemed clinically stable, she was discharged home.

No, the Inpatient admission was not medically necessary.
The care as provided was medically appropriate; however, the level at which the care was rendered was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain and colitis; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease.
Treatment: Inpatient admission.
The insurer denied the Inpatient admission.
The denial is overturned.

The patient is male with a past medical history significant for CAD (coronary artery disease), status post prior multiple PCI (percutaneous coronary interventions), obesity, COPD(chronic obstructive pulmonary disease), HTN (hypertension), dyslipidemia, and sleep apnea. He presented  with new onset SVT (supraventricular tachycardia) with heart rate to 170 bpm (beats per minute). The patient's labs were notable for elevated troponins, peaked at 0.456. The patient was hemodynamically stable. He was transferred to the ED. Initially a cardiac catheterization was planned, however a decision was made to treat his Type 2 MI (myocardial infarction) conservatively. The troponin elevation was felt to be due to demand ischemia in the setting of recurrent SVT (supraventricular tachycardia), and he was referred for an ablation procedure. 

The patient underwent ablation procedure  and was discharged home with a plan for outpatient follow-up.

The Inpatient admission was medically necessary. 
The patient with known CAD (coronary artery disease), status post prior PCI (percutaneous coronary intervention), with multiple comorbidities, presented with new onset SVT (supraventricular tachycardia), complicated by Type 2 myocardial infarction, as evidenced by troponin elevation. Given the presentation, evidence of myocardial injury, and risk of cardiac complications, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is an adult male with hypertension who presented to the emergency department with cough and dyspnea. Initially, he had severe hypertension.  Diagnoses included congestive heart failure (CHF), chronic kidney disease (CKD), and hypertension. 

The patient's echocardiogram showed decreased ejection fraction, mitral regurgitation (MR), and left atrial enlargement. Chest x-ray showed evidence of congestive heart failure and possible pulmonary hypertension. The patient was diuressed, placed on medical therapy including three anti-hypertensives  with good response.  He was seen by Nephrology. The patient's creatinine increased from 1.45 to 1.68 in one day. White blood cell (WBC) count increased to 16.9 thousand. His blood pressure normalized and the patient improved. The patient was transferred for cardiac catheterization at another hospital.

Yes, the proposed inpatient admission was medically necessary.
This is a new onset of likely ischemic cardiomyopathy in the setting of hypoxia, malignant hypertension, progressive renal failure, leukocytosis, significant mitral regurgitation, and probable pulmonary hypertension. 

The diagnoses and treatment of these conditions require a complex set of testing and intervention. This includes the proposed cardiac catheterization, the adjustment of multiple medications which could lead to worsening renal failure, frequent - at least daily - blood draws and adjustments, and possible further deterioration of renal function.

Community practice and guidelines support inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Cystitis.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient has end stage renal disease status post kidney transplant admitted for viral cystitis.   She was evaluated by the infectious disease (ID) service. The patient was treated with anti-viral and was discharged.

The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain, she was able to tolerate oral diet and did not total parenteral nutrition and her condition responded to antibiotics within 48 hours.

There is no evidence-based literature inpatient level of care was medically necessary and her condition could be treated safely under lower level of care. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.