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

Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was abnormal, consistent with ischemic changes. The presentation was in the setting of hypertensive urgency. A stress test was abnormal as well, consistent with ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended. Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit.  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: Upheld

Diagnosis: Rectal bleeding
 
Treatment: Inpatient admission, monitoring

The insurer denied the inpatient hospital admission. The denial was upheld.

The patient presented with rectal bleeding. The patient initially had dizziness, but at the time of admission the dizziness had resolved. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. A rectal exam did not reveal any bleeding. The hemoglobin was 13.8. The bleeding was felt to be due to hemorrhoids. The patient was treated for constipation and referred to Gastrointestinal (GI) clinic. 

Clinical indications for admission for lower GI bleeding (M-182) include having ongoing active bleeding, failure to control bleeding after a colonoscopy, coagulopathy, intestinal obstruction, and severe thrombocytopenia. The patient did not have these conditions. The patient also did not have hemodynamic instability, severe anemia, severe pain or an inability to maintain oral hydration. 

This patient had minor self-limited bleeding. The patient remained hemodynamically stable and there was no evidence of active ongoing bleeding. The patient did not meet MCG criteria for admission for lower GI bleeding. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

This is a child with known sickle cell disease HbSS, who presented with fever and upper respiratory infection (URI) symptoms for 3 days along with loose stools for 4 days. The patient was with a poor appetite x 1 week. Temperature maximum was 101. A chest X-ray showed questionable pneumonia. The patient was given intravenous (IV) Ceftriaxone and admitted to the hospital. The patient had multiple admissions since birth. The patient received packed red blood cells (PRBC) in the past. On this admission the white blood cell count (WBC) was 15,100 and hemoglobin (Hgb) was low at 6.4. The liver function tests (LFTs) were normal. The respiratory syncytial virus (RSV) and flu tests were negative. Blood cultures were done. On physical exam the patient was in no acute distress. The lips were mildly dry. The patient had harsh breath sounds. The Abdomen revealed a liver 2cm below the right costal margin. The registered nurse (RN) documented the child to have dry cracked lips with furred tongue and also looking weak. After admission the spleen was palpable at the left costal margin with inspiration. His WBC increased to 23.3 later on the day of admission. The patient was followed and intravenous fluids (IVF) were administered. The Hgb went up to 7.0 during admission.  The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Inpatient Hospital Admission is medically necessary for this patient. There was a new infiltrate on X-Ray. This would be indicative of acute chest syndrome (ACS). "Clinically, ACS is defined by a new pulmonary infiltrate on chest radiograph in addition to one or more of the following: fever, tachypnea, dyspnea, hypoxia, and chest pain. ACS is a common and potentially lethal complication of sickle cell disease." This patient has had transfusion of PRBCs in the past. The low hemoglobin coupled with diarrhea, poor (PO) intake and physical signs of dehydration would also predispose the patient to crisis due to  sickle cell. IV hydration, monitoring  Intake's and Output's, (PO) intake, stool output as well as fever curve and O2 saturation would be proper care for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Issue conceiving
Treatment:  IUI
The proposed treatment with IUI was not medically necessary.

According to the American Society for Reproductive Medicine (ASRM), infertility is a disease, defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination.  Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35 years.

This patient was able to conceive following donor insemination but had a miscarriage.  In other words, she did not fail to conceive after six therapeutic donor inseminations, and, therefore, she does not have a diagnosis of infertility.  In the absence of such a diagnosis, treatment for infertility including the intrauterine insemination performed is not medically necessary.

The request is not medically necessary, since this patient did not have an illness, injury or disease:  She has inability to conceive due to non-exposure to sperm and due to aging a normal, natural physiological process.  The standard of care is for this patient to fail six inseminations (i.e. fail to get pregnant) before she is considered infertile and eligible for coverage of infertility services.

In summary, this patient's inability to conceive is due to natural aging and non-exposure to sperm.  She does not have a diagnosis of infertility, and the requested coverage for IUI was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to the hospital. The patient has a past medical history of Parkinson's disease and hypertension and presented after a syncopal episode. The patient was noted to be unresponsive and cardiopulmonary resuscitation (CPR) was initiated. Vital signs showed a blood pressure of 185/71, pulse 97, respiratory rate 18 and oxygen saturation 96%. Labs showed a white blood cell count of 7.3, hemoglobin 9.2, platelets 158, sodium 140, potassium 3.6, creatinine 0.8 and a glucose of 113. An electrocardiogram (EKG) showed sinus rhythm with frequent PVCs (premature ventricular contractions). A computed tomography (CT) of the brain showed no acute intracranial abnormalities. The patient was admitted for further management and evaluation. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented after a syncopal episode. Her EKG showed sinus rhythm. The head CT was negative for acute intracranial abnormalities. The patient was hemodynamically stable. An ultrasound (US) carotid showed no stenosis. No sustained ectopic foci were noted on Holter. Amantadine and Donepezil were discontinued per neurology recommendation. The patient was started on Ropinirole and Sinemet. She was also evaluated by physical therapy. No complicating events occurred during the stay. This patient's care could be provided at a lower level as there was no hemodynamic instability, pulmonary embolism, arterial dissection, acute congestive heart failure exacerbation, cardiac ischemia, atrial fibrillation or need for continuous intravenous infusion.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient is a male with a significant past medical history for diabetes mellitus, hypertension, chronic kidney disease, gastroesophageal reflux disease and nephrolithiasis. The subject under review is for the medical necessity of increase in personal-care service hours from 17 hours a week to 40 hours a week. The patient has currently been approved for 17 hours a week. The patient requests additional services to 40 hours a week. The health plan's determination is overturned, in part. The requested health service/treatment of Consumer directed personal cares assistance services increase from 17 to 40 hours per week is not medically necessary for this patient. However, an increase to 20 hours a week is medically necessary.
The patient's son stated that the patient needs assistance with feeding, medication, and walking. He reports the current hours are not enough, and are not adequate for bathing, dressing, toileting, and housekeeping related services. Per the Uniform Assessment System - New York Comprehensive Community Assessment Report, the patient is independent with eating, ambulates in his own home with an assistive device, and is continent of bowel and bladder. The Uniform Assessment System - New York Comprehensive Community Assessment Report recommended a total of 19 hours a week for personal care services. Based upon review of the records provided along with the documents provided in regards to nursing and aid hours, the patient would need additional hours to support basic functions such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The recommended increase in the personal-care hours from 17 hours a week to 20 hours a week should be sufficient to maintain activities that were noted to be medically necessary according to the documentation provided. There is no medical need for additional hours other than 20 hours a week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, shortness of breath
 
Treatment: Inpatient admission, diagnostic testing, medication, monitoring

The insurer denied the inpatient hospital admission. The denial was upheld.

The patient presented to the Emergency Department (ED) with acute onset of chest pressure and diaphoresis. The patient reported right lower extremity cramping and left lower extremity swelling. The patient has a productive cough with green sputum and mild rhinorrhea. The patient has a past medical history of Marfan syndrome, Diabetes Mellitus type II, previous heart attack, status post mechanical aortic valve replacement (AVR), status post left heart catheterization with percutaneous coronary intervention (PCI) and recent admission due to melena and hematochezia. The patient had symptoms of an upper respiratory infection (URI), shortness of breath with intermittent paroxysmal nocturnal dyspnea (PND). The patient states that for the past few days The patient has had sub sternal pressure like chest pain which is similar to when The patient was diagnosed with non-ST elevated myocardial infarction (NSTEMI). The patient states that the pressure radiates to his back but only when The patient is laying down and reports that this is been ongoing for the past month. His vital signs include temperature 36.6 C, heart rate 60, blood pressure 169/80, respirations 18 and oxygen saturation 99% on room air. 

The patient's atypical chest pressure/congestion resolved after receiving intravenous (IV) Lasix. The symptoms were not typical for acute coronary syndrome (ACS). In the hospital The patient did not have any recurrence of significant chest pain and his workup revealed normal troponins and a BNP that was only slightly elevated. His Electrocardiogram (EKG) showed no change from previous recordings and no evidence of acute myocardial injury or ischemia. An echocardiogram and a Computer Tomogram (CT) of the chest did not reveal any significant pathology. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and Chest Pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 

This is a female with a history of pulmonary embolism who presented to the ER for further evaluation/management of dyspnea and chest pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received therapeutic anticoagulation, supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient , who requests an increase in personal-care assistant hours from 70 hours a week to 112 hours a week. The patient has a past medical history significant for hyperlipidemia, diabetes mellitus type 2, hypertension, and cognitive dysfunction.  The health plan's determination is upheld.  The requested health service/treatment of personal care assistance increase from 70 hours per week to 112 hours per week is not medically necessary for this patient.  Additional services are not medically necessary. Typically for services to be considered medically necessary the aide must be functioning and performing ADLs and/or IADLs.  It is noted that the patient's ADLs and IADLs can be performed within the allotted time.  Services for monitoring for safety or companion care without the necessity of underlying ADLs or IADLs are not considered medically necessary.  No additional hours are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease
 
Treatment: Medication- Humira

The insurer denied treatment with Humira. The denial was upheld.

The patient is a child with long standing constipation, diagnosed with Crohn's disease. His Gastroenterologist is requesting authorization for Humira.  Bloodwork showed a platelet count of 662, albumin 3.0, CRP 67.6, ESR of 53. Patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Pathology report demonstrates chronic ileitis with granuloma, colitis. Patient was started on steroids, which improved many of his symptoms. Plain x-ray shows constipation. Recent emerging data has demonstrated disproportionate risks of hepatosplenic T-cell lymphoma among adolescent males exposed to immunomodulators.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: SOB; Wheezing
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient had asthma exacerbation with failed outpatient therapy, emergency room therapy. The patient had history of similar asthma exacerbations in the past with requiring mechanical ventilation. Since the patient failed outpatient as well as emergency room treatment and had significant anxiety symptoms during early hospitalization stay, the acute in hospital level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes type II, status post mechanical fall
Treatment: Inpatient admission
The inpatient admission as not medically necessary.

The patient is a female with past medical history of schizophrenia and type II DM (diabetes mellitus). She was seen at the emergency room, after a trip and fall with laceration to the forehead.  She denied headache, abdominal pain, neck pain, back pain, numbness, weakness, and vision changes. 

The patient's vitals were as follows: BP (blood pressure) 104/71; P (pulse) 95; RR (respiration rate) 16; Temp 36.6C; SpO2 (pulse oximetry) 95% on room air.  On physical examination, there was a 1.0 cm subcutaneous linear shaped, injury to the right forehead.  No neurology exam, motor strength was 5/5, sensation intact, cranial nerves intact; normal gait.  She was awake, alert and oriented times three.  She had mild tenderness in the right knee.  

The patient's laboratory studies revealed the following: urinalysis was unremarkable; hemoglobin was 12.2, hematocrit 36.3, platelet 206, WBC (white blood count) 8.7, potassium 3.7, sodium 143, and creatinine 0.7.  CT of the cervical spine and head demonstrated no evidence of acute pathology.  Chest x-ray showed no evidence of acute cardiopulmonary disease.  EKG (electrocardiogram) showed normal sinus rhythm (NSR) at 70 bpm.  Right knee x-ray revealed mildly comminuted vertically oriented fracture of the mid to lateral patella with minimal displacement; moderate suprapatellar effusion.  Impression included unspecified fall, and vertical patellar fracture. 

Medical records noted that the patient lives alone, with no home care; She has had two falls in a week and ambulates with unsteady gait in the emergency room.  It was noted that patient has poor insight, poor historian and unable to care for herself, will require admission for placement.  Management included placement in knee immobilizer, Weight bearing as tolerated, RLE (right lower extremity) elevation; it was recommended that she follow with outpatient orthopedics.  While on admission, she was seen by physical therapy. 

On the day of discharge, the patient was medically stable for discharge home.   It was noted that she will receive home care. 

The patient was admitted to the hospital following a fall, and was diagnosed with patellar fracture, and mild laceration of the forehead.  Recommended treatment was conservative as well as outpatient follow-up by orthopedic specialty.  She was hemodynamically stable when she presented to the emergency department.  There was no evidence of altered mental status, confusion, respiratory compromise, significant persistent life-threatening arrhythmias, or sepsis.  There were no serious neurologic abnormalities like brain infection, cerebral bleeding/ischemia, increased intracranial pressure or spinal cord injury.  CAT scan of the brain did not show any acute bleed or hemorrhage.  

In view of the foregoing, the inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Varicose veins
Surgical services

The patient presented with right leg symptomatic varicose veins. Main symptoms include burning, aching and throbbing. The patient has attempted and failed conservative therapy with graded compression stockings for several months' duration. The symptoms are lifestyle limiting and interfere with  activities of daily living. A duplex scan demonstrates reflux in the right accessory great saphenous vein. The health plan's determination of medical necessity is overturned in whole. Endovenous ablation of the right accessory great saphenous vein for this patient is the current standard of care treatment for symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results. Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent c.i. 680 to 820), 599 (521 to 677) and 813 (751 to 876) per cent respectively after 1 year.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of substance use disorder who presented  with a request for detoxification services after relapsing. The patient was using heroin with up to 5 bags with intranasal administration on a continuous daily basis together with use of a prescribed benzodiazepine. She has a history of a mental disorder best characterized as schizophrenia treated with quetiapine, and major depressive disorder. She has a history of psychiatric hospitalizations. The health plan's determination of medical necessity is upheld.
The continued treatment could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of schizophrenia and ongoing substance use disorder with heroin and a prescribed benzodiazepine. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or acute symptoms of psychosis, or perceptual disturbance that would have warranted inpatient level treatment for the time interval under review. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had no complications that required continued withdrawal management or general medical services, as noted in the clinical summary. The patient had fair insight and control of impulses and was cooperative and generally motivated to continue with substance use disorder treatment.