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

Diagnosis: cough/fever
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a young boy who presented with cough and fever. He was well until 8 days prior to presentation when he developed a cough. He also had a tactile fever at that time. The cough was productive with associated rhinorrhea and congestion. He was receiving tylenol at home but continued to have tactile fevers. He then developed vomiting that was often post-tussive and he was unable to keep anything down. He also developed decreased wet diapers, and therefore was brought to the emergency department for care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a very young boy who presented with more than 5 days of fever as well as decreased oral intake and vomiting. He was febrile at the time of presentation and had an elevated CRP. There was concern for possible Kawasaki Disease, which requires careful evaluation and prompt treatment to prevent potentially serious morbidity including coronary artery aneurysm. He also had vomiting and was unable to tolerate oral intake. Combined with increased insensible fluid loss due to fever, he needed intravenous fluids to maintain his hydration status. He therefore required hospital admission for treatment with intravenous fluids as well as careful monitoring with an escalation of therapy if needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer.
Treatment: Inpatient stay.

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

The patient is a female who presented to the emergency department (ED) complaining of severe, worsening left-sided chest and back pain. She also reported left breast enlargement and erythema. Her medical history was remarkable for prediabetes. In the ED, her blood pressure was 140/96 with a heart rate of 98 beats/minute. Her respiratory rate was 18/minute with a room air oxygen saturation of 99% (percent). A computed tomography (CT) scan showed numerous nodules in both lungs, left axillary adenopathy, nodular lesions in the left breast, diffuse metastatic lesions in the liver and bones and pathologic compression fractures in multiple vertebrae. The patient was treated with ketorolac and morphine and was admitted to the hospital for management of intractable pain due to widely metastatic cancer. She continued to complain of severe pain despite treatment with morphine and fentanyl.

Based on the documentation provided, an inpatient hospital admission was medically necessary.

This woman was admitted to the hospital with severe pain due to widely metastatic cancer. Her pain continued despite treatment with multiple high dose opioids, gabapentin and mirtazapine. She required daily adjustment and medication dosage increases. She was treated with antibiotics for fever and underwent axillary lymph node biopsy. She was seen in consultation by multiple specialists, including an oncologist, a palliative care specialist and an infectious disease specialist. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: alcohol withdrawal
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a male with a history of alcohol use disorder who initially presented to the emergency department with concerns for abdominal pain, nausea and vomiting. Last alcohol intake was the night prior. Initial vital signs revealed a heart rate (HR) 105, blood pressure (BP) 126/97, respiratory rate (RR) 21, and pulse oximetry 100% (percent) on room air. Initial examination documented the patient as alert, oriented, and with visible tremors. 

The inpatient hospital admission was medically necessary. The patient in this case had a history of alcohol use disorder who presented with abdominal pain, nausea and vomiting. Initial evaluation revealed tachycardia, tremor, lactic acidosis, high anion gap metabolic acidosis, and electrolyte derangements. The initial CIWA (Clinical Institute Withdrawal Assessment) was 13 and the patient was treated with benzodiazepines. In addition, the patient stated suicidal ideations with a plan and was placed on suicide precautions. Psychiatry was consulted and documented clearly that the patient was an imminent danger to self with recommendations to remain on 1:1 observation with possibility for inpatient psychiatric care once medically stable. Following observation care, psychiatry re-evaluated and documented for the patient to remain on 1:1 observation. Following several days, psychiatry cleared the patient for follow-up and the patient left against medical advice. Moreover, clinical indications for admission to inpatient care were met. The patient presented with a substance-related disorder appropriate for inpatient level of care as indicated by psychiatrist-deemed imminent danger to self with a current plan for suicide. Treatment services included continuous 1:1 observation necessary at an inpatient level of care. Voluntary treatment at lower level of care was not feasible.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tubo-ovarian abscess (TOA)

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient was diagnosed with a tubo-ovarian abscess (TOA). TOA is a serious and potentially life-threatening condition. Aggressive medical and/or surgical therapy is required, and rupture of an abscess may result in sepsis. For patients with ruptured abscesses, current mortality rates may be as high as 1.7 to 3.7 percent. It is agreed that the presence of a TOA requires emergent hospital management. Experts agree that women with a TOA should be treated as an inpatient with intravenous antibiotics, at least initially. This is consistent with the recommendation by the United States Centers for Disease Control.

It is unclear, based on the submitted documentation, why the patient was transferred from one hospital to another. Usually, transfer to another hospital is medically necessary if the services are not available (CONDITION NOT MET) or if changing hospitals will affect the quality of care (CONDITION NOT MET). Based on all the available information, the patient's TOA could have been treated at the first hospital without affecting the quality of care.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cystic hygroma/lymphatic malformation of the neck.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient is a young child who has a history of a cystic hygroma/lymphatic malformation of the neck. He was receiving sirolimus. He presented with a three-day history of fever. He was admitted after a dose of antibiotics and discharged home after the blood culture was negative.

The member presented with a fever. There was no evidence of infection for the member's cystic hygroma present. There was no change in vital signs, hypoxia or other documented medical conditions which indicated that the member required inpatient hospitalization. The member could have been safely managed at a lower level of care.      

"Lymphatic malformations are low-flow vascular malformations that arise due to errors in vascular development. Lymphatic malformations are benign and usually noted at birth or in the first few years of life. Lymphatic mass lesions are composed of varying size of cysts; this article focuses on discussion of cystic lymphatic malformations. Lymphatic malformations can occur throughout the body especially in lymphatic rich areas such as the cervical and axillary locations, as well as the groin, trunk, retroperitoneum, extremities, abdominal or thoracic cavities. Treatment options vary based upon size of cysts and location. A multimodal and interdisciplinary approach is essential to care for patients with lymphatic malformations. Management options include observation, pharmacotherapy, sclerotherapy, and surgical procedures" (Kulungowski, A. M., & Patel, M. 2020).

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:  Left lower leg pain, erythema, and swelling.
Treatment:  Inpatient admission.

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

This is an adult male with a benign past medical history, who presented to the emergency department with complaints of left lower leg pain, erythema, and swelling following an insect bite.

Vitals on presentation included: Temperature 98 degrees Fahrenheit, Blood Pressure 141/77 mmHg (millimeters of mercury), Pulse 99 beats per minute, Respirations 16 breaths per minute, Oxygen saturation 98% on room air. Laboratory results included the following: White blood cell (WBC) count 12.3, Hemoglobin (Hgb) 13.3, Hematocrit (Hct) 40.6, creatinine-0.95, glucose-99.

The patient was started empirically on intravenous antibiotics (vancomycin and Unasyn) for left lower extremity cellulitis. Duplex ultrasound was negative for deep venous thrombosis (DVT). X-ray of tibia/fibula was negative for fracture but showed soft tissue swelling. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Augmentin and doxycycline) as an outpatient.

According to the documentation, the patient presented with left lower leg cellulitis. Otherwise, he was afebrile, hemodynamically stable, with unremarkable laboratory results except for a mildly elevated white blood cell (WBC) count. The patient had no evidence of a disseminated infection, no co-morbid conditions, and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management. 

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of hypertension and alcohol use disorder who initially was directed to the emergency department for concerns of severe hypertension. Additional history included significant daily alcohol use without a history of alcohol withdrawal, seizures, or hallucinations. Initial vital signs revealed a temperature of 98.2F, heart rate (HR) 120, blood pressure (BP) 209/141, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination documented the patient as alert, oriented, tremulous, with tongue fasciculations, and in no acute distress. Clinical Institute Withdrawal Assessment (CIWA) score was 16. 

The inpatient hospital admission was not medically necessary. The patient had a history of hypertension and alcohol use disorder without associated withdrawal who was directed to the emergency department for concerns of severe hypertension. Initial examination documented the patient as tachycardia, hypertensive, alert, oriented, without focal neurological deficits, and with a CIWA of 16. Initial evaluation did not reveal evidence of end organ dysfunction. Hypertension and withdrawal symptoms improved with emergency department care. The admitting physician documented a principal problem of hypertension with no detailed assessment and plan regarding alcohol withdrawal. Primary treatment included initiation of oral anti-hypertensives. Following observation care, hemodynamics were stable and the patient was deemed medically stable for discharge. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied braces and monthly visits.
The determination is upheld.

This is a female patient with a Class II right malocclusion, severe maxillary crowding and mild mandibular crowding, mild overjet and mild overbite, ectopic eruption of maxillary cuspids which are erupting labially. At issue is whether the braces and monthly visits are medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 23 with no auto qualifiers. Auto qualifiers include cleft palate deformity or craniofacial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment of braces and monthly visits is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decrease in kidney function
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who was admitted for worsening kidney function on outpatient labs with hyperkalemia. She was evaluated by nephrology service and was started on intravenous fluid and treated with Lokelma for elevated potassium level. The patient was noted to have adequate urine output and her creatinine was trending down appropriately, which was consistent with prerenal azotemia. Her condition stabilized and she was discharged on day #4.

The requested health service was not medically necessary.

The patient was admitted for dehydration and was noted to have elevated creatinine; however, the patient's acute kidney injury could have been treated safely under a lower level of care. The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent acute tubular necrosis. This patient's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis, which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy. In addition, she was hemodynamically stable and was able to tolerate an oral diet. When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, she had no requirements for inpatient level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder, and diabetes mellitus type 2
Treatment:Consumer Directed Personal Assistance Program (CDPAP) services 4.5 hours/day, 7 days/week, to total 31.5 hours/week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) services 4.5 hours/day, 7 days/week, to total 31.5 hours/week
The determination is overturned.

The patient is a female with a past medical history of hyperlipidemia, vitamin D deficiency, obesity, bipolar disorder, and diabetes mellitus type 2 who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 2.5 hours/day, 7 days/week, to total 17.5 hours/week based on assessment. The tasking tool estimated 17.5 hours/week.
There was a request to increase CDPAP services and the patient underwent a video assessment Notes from the assessment noted the patient lived with her daughter in a 2 bedroom apartment and had a decline in activities of daily living (ADL) status and a deterioration of overall self-sufficiency in the last 90 days. The tasking tool estimated 24.5 hours/week.
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient would benefit for more home care hours, specifically 4 hours/day, Monday through Sunday. The insurer sent final adverse determination denial notice continuing to deny the request to increase CDPAP services noting patient's assistance needs and granting additional hours when tasks are not being performed and for safety monitoring and supervision are not a covered benefit. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) services 4.5 hours/day, 7 days/week, to total 31.5 hours/week.

The services are medically necessary. There is documentation from the patient's medical provider of medical necessity of increased CDPAP services. The plan's tasking tool estimated 24.5 hours/week of assistance based on an assessment yet only approved 17.5 hours/week. The tasking tool underestimated the patient's care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 4.5 hours/day, 7 days/week, to total 31.5 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, dizziness, heart failure
Treatment: Increase Consumer Directed Personal Assistance 
(CDPAP) Services to 8 Hours per Day - 7 Days per Week - for a Total of 56 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance (CDPAP) Services to 8 Hours per Day - 7 Days per Week - for a Total of 56 Hours per Week
The denial is overturned.

This is an elderly male patient that has medical conditions that include Alzheimer's dementia, dizziness, heart failure, vertigo, and leg weakness. The denial of an increase in consumer 
directed personal assistance (CDPAP) services for a total of 56 hours per week is being appealed. The health plan approved consumer directed personal assistance services (CDPAP) 4 hours per day, 7 days per week for a total of 28 hours per week.
Uniform Assessment System (UAS) evaluation completed 3 months ago shows modified independent cognition and functional status: total dependence with shopping; maximal assistance with managing medications; extensive assistance with managing finances, bathing, lower body dressing, walking, locomotion, toilet transfer, and bed mobility; limited assistance with personal hygiene, upper body dressing and toilet use; and independent with eating. The patient has occasional bladder incontinence. He uses a walker for ambulation. He reports a fall 5 months ago. 
Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with lower body dressing toileting, bathing, walking, locomotion, and bed mobility. 
A statement from the provider reports the patient has progressive dementia, weakness, and falls.

The requested health service is medically necessary.

This patient has multiple chronic conditions. The denial of an increase in consumer directed personal assistance (CDPAP) services for a total of 56 hours per week is being appealed. The 
health plan approved consumer directed personal assistance 4 hours per day, 7 days per week for a total of 28 hours per week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living, except eating. He has occasional bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with lower body dressing toileting, bathing, walking, locomotion, and bed mobility. The appeal statement report's the patient has progressive dementia, weakness, and falls. Based on the Uniform Assessment System evaluations, this patient has significant limitations with activities of daily living that have progressed. The approved consumer directed personal assistance 28 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living as noted above. The proposed consumer directed personal assistance services for a total of 56 hours per week is indicated.