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

Diagnosis: Left submandibular abscess following a dental extraction. 
Treatment: Hospital Admission. 

The insurer denied coverage for the Hospital Admission. 

The denial is overturned. 

This is a male patient with a benign past medical history who presented to the Emergency Department (ED) with complaints of submandibular swelling following a dental extraction 4 days prior. The patient's vital signs on presentation included: Temperature 98.5, Blood Pressure 122/77, Pulse 97, Respiratory Rate 18, Oxygen Saturation 97% on room air. The patient's laboratory values were notable for the following: white blood cell (WBC) count 24.7, hemoglobin 13.7, hematocrit 41.8, creatinine 0.92, and glucose 94. 

The patient was empirically started on intravenous (IV) antibiotic (Unasyn) as well as Decadron to minimize oral swelling. The patient's computed tomography (CT) scan of the neck showed a large sublingual abscess 4.6 x 2.5 x 1.6 centimeters (cm). Oral and maxillofacial surgery evaluated the patient and performed incision & drainage procedure with placement of two Penrose drains. Wound cultures revealed gram positive cocci in pairs and clusters. The patient remained afebrile, hemodynamically stable and clinically improved. Drains were removed, and the patient was discharged to continue oral antibiotics as an outpatient. 

The patient presented with left submandibular abscess following a dental extraction. Although the patient was afebrile, hemodynamically stable, the patient had significant swelling as described by trismus, change in voice, and inability to tolerate sips of water. Induration and edema of sublingual area/floor of mouth was also noted. Laboratory result showed significant elevation of White Blood Cell (WBC) count. Based on above findings, hospital admission was medically necessary for administration of IV antibiotics, steroids, and surgical intervention. 

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

The carrier's denial of coverage for the Hospital Admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This patient is a male child who was brought to the Emergency Department (ED) by his mother after she witnessed a fall from his bed where he hit the front of his head.  The patient did not cry right away and he was just staring.  At the time of triage, the baby was acting appropriately.  At the time of the initial assessment, the patient's mother reported he was playing on his bed and fell from around 2 feet to 3 feet of height.  His vital signs included a heart rate of 183, respiratory rate of 30, and temperature of 98.3.  His oxygen saturation was 98% on room air.  A level 2 trauma was called for him to be evaluated.  Upon evaluation the patient was awake and alert well-appearing.  There was a 2 centimeter (cm) diameter hematoma on the frontal scalp.  After a conversation with the trauma team and mother, the patient was to be observed in the pediatric intensive care unit (PICU) with serial neuro checks.  The trauma team requested a Computed Tomography (CT) scan of the head.  The CT scan revealed no other acute findings other than a frontal scalp hematoma. The Pediatric Glasgow Coma Scale score was 15. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient. 

Literature indicates a pediatric patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new and persistent focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with some confusion, but the symptoms resolved quickly without intervention. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The patient did continue to slowly improve and was discharged the following day. 

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: Acute bronchitis.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a male patient with a past medical history of asthma who was brought by Emergency Medical Services (EMS) to the Emergency Department (ED) because of chest pain and headache that began the previous evening. The chest pain was described as sharp. It was 6/10 in intensity and episodic. He was transferred from the ED to inpatient status with the admitting diagnosis of acute bronchitis. The assessment and plan stated that the patient had acute bronchitis, but no evidence of pneumonia. He had atypical chest pain and had periods of chest tightness that lasted approximately five minutes and then resolved spontaneously. These have occurred with exertion and raise the possibility of acute coronary syndrome (ACS). The plan of care stated that the patient would be admitted to telemetry, he was given aspirin 325 milligrams (mg) and they will hold beta blocker until urine toxicology has been reviewed. A note described the patient's hospital course stating that he was managed in a telemetry unit for chest pain to rule out ACS. 

High-sensitivity cardiac troponins T (hs-cTnT) have been introduced as a highly sensitive and early biomarker of myocardial damage. (1) In two prospective cohorts of patients admitted to the hospital for chest pain, undetectable hs-cTnT was found to have a very high negative predictive value for myocardial infarction (MI). (2, 3) Multiple observation protocols have been developed which have been shown to be safe and deliver effective care. Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit. (6, 7)

This patient presented to the ED with a complaint of chest pain and headache. His troponins were negative and his electrocardiograms (ECGs) showed no ST-segment (the flat, isoelectric section of the ECG between the end of the S wave and the beginning of the T wave) changes consistent with myocardial injury and were within normal limits. He was placed in a telemetry unit at the time of admission, which was not medically necessary. 

Literature shows that unless there is clinical likelihood of arrhythmia, there is little chance that an arrhythmia will be seen. Literature also recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing. A monitored level of care for this patient was not necessary. 

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

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

Diagnosis: Dental Problems (oligodontia in the maxilla and mandible; moderate periodontal alveolar bone loss corresponding to periodontal disease, but otherwise essentially stable alveolar bone height without severe periodontal disease).

Treatment: D5212 Partial Lower Denture.

The insurer denied coverage for D5212 Partial Lower Denture.

The denial is overturned. 

This is a female patient who presented with pain for evaluation and comprehensive dental care. Recommended treatment was for a mandibular removable partial denture to restore function. 

Upon review of the documentation, in particular the panoramic radiographs, the patient exhibits oligodontia in the maxilla and mandible. Review of the remaining dentition on radiograph indicates a level of moderate periodontal alveolar bone loss corresponding to periodontal disease, but otherwise essentially stable alveolar bone height without severe periodontal disease. The teeth that would be supports for the removable partial denture are stable and would be adequate abutment teeth. This treatment is a standard of care in dental practice for this clinical circumstance. As this is a covered service and indicated for restoration of function and occlusal stability, the partial denture is considered medically/dentally necessary.

Reverse denial and approve lower partial denture as partial dentures are designed for use in this clinical circumstance, are a covered service for this patient, are a standard of care in general dental practice and would be an appropriate treatment to restore function and occlusal stability.

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

The request for D5212 partial lower denture is considered medically necessary for this patient.

The medical necessity for D5212 Partial Lower Denture is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic cervical cancer.
Treatment: Transfer to another Hospital for acute Inpatient Hospital Admission for End of Life Care.
The insurer denied coverage for the transfer to another Hospital for acute Inpatient Hospital Admission for End of Life Care.
The denial is upheld. 

This is a female patient whose medical history includes metastatic cervical cancer and heart failure.  The patient was previously hospitalized, transferred to an acute rehab facility then transferred back to the hospital when she began having fevers and worry for sepsis.  In the hospital it appears the patient's health status deteriorated. A request has been made for transfer to another hospital.

According to the History and physical, there was a chief complaint of fever.  The plan was to continue with meropenem and vancomycin treatment. The plan was for management of heart failure. According to a progress note 14 days after the History and physical, acute inpatient admission to another hospital was requested.  The patient was noted to have issues of need for oxygen, gastrointestinal (GI) and genitourinary (GU) bleeding, pyelonephritis. The patient had a do not resuscitate (DNR) order. The insurer's Adverse Determination Denial notice informed the patient that the request of service was felt to be not medically necessary.  The notes indicate that it was felt that the patient's current hospital could support her wishes for end-of-life care rather than transfer to a different hospital.

This patient was clinically deteriorating and has multiple medical problems.  Once the patient's DNR order was signed, there was a request for transfer to a different hospital for end-of-life care. Per the case notes, the patient's health coverage policy states that the patient must have an active, acute ongoing problem for which she was being treated and that the current facility was unable to provide care that she needed. Given that she was receiving critical care at the hospital at which she had been admitted for several days, it is highly unlikely that this hospital cannot provide her end-of-life care. Therefore, this patient's end-of-life care needs can be performed at her current facility.

The carrier's denial of transfer to another Hospital for acute Inpatient Hospital Admission for End of Life Care is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low hemoglobin and evidence of iron deficiency.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with no significant past medical history who presented with a hemoglobin of 6, hematocrit of 20 and an mean corpuscular volume (MCV) of 56.8 who has a history of heavy menses. She had pallor but was otherwise asymptomatic. White blood cell count (WBC) and platelet counts were normal with no evidence of abnormal cells. The patient was admitted on  for a blood transfusion and was discharged on oral iron supplementation.

No, the proposed inpatient admission was not medically necessary.

Based on the provided medical records, the patient did not require inpatient hospitalization. The patient presented with a hemoglobin of 6 and evidence of iron deficiency. The patient received a blood transfusion. These services could have been safely provided at a lower level of care. The patient had no symptoms of anemia and did not have evidence of hemolysis or hemorrhage.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease and Hypertension.
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services 12 Hours Per Day- 7 Days Per Week. Total of 84 Hours Per Week.
The insurer denied the Consumer Directed Personal Assistance Program (CDPAP) Services 12 Hours Per Day- 7 Days Per Week. Total of 84 Hours Per Week.
The denial is overturned. 

The patient is a female with a history of Parkinson's Disease and Hypertension. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.

Review of the patient's medical records from a recent clinic visit with her medical provider indicates that due to worsening functional status, muscle strength and gait ataxia, the patient is now completely wheelchair-bound and requires complete assistance with transfers, toileting, showering and dressing. Hence, the currently approved plan of 59.5 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is upheld. 

The patient is a male who presented to the hospital for scheduled cardiac catheterization and percutaneous coronary intervention (PCI). He had suffered an acute non-ST segment elevation myocardial infarction. Cardiac catheterization at that time showed severe multi-vessel disease. Coronary artery bypass graft surgery was recommended but the patient declined. Thus, he was scheduled for the procedure. At the time of presentation, he was hemodynamically stable. He was treated pre-procedure with intravenous fluid and acetylcysteine for a serum creatinine of 1.5 milligrams per deciliter (mg/dl). He then underwent atherectomy and stent implantation for a chronic total occlusion of the left anterior descending coronary artery, balloon angioplasty of the right coronary artery, and unsuccessful intervention in the mid-right coronary artery. Post-procedure, the patient was hemodynamically stable and was admitted to the hospital. His serum troponin level rose to .03 nanograms/milliliter (ng/ml). An echocardiogram showed a left ventricular ejection fraction of 40-45%. The patient was discharged.

The subject under review is the medical necessity for an inpatient stay.

The inpatient stay is not medically necessary.

This patient presented for scheduled percutaneous coronary intervention (PCI). He was hemodynamically stable upon presentation and there were no procedural complications. He had a mild troponin elevation post-procedure, which is common after PCI. Minimal elevation such as this patient had does not meet criteria for PCI associated myocardial infarction (type 4a MI). While same-day discharge after elective PCI has been shown to be safe for many patients, this patient had a number of features that warranted monitoring post-procedure, as opposed to same-day discharge, including kidney disease, PCI for chronic total occlusion, atherectomy, and multi-vessel PCI. However, this did not warrant an inpatient stay. Per the expert consensus document from the Society for Cardiovascular Angiography and Interventions, in the absence of ST segment elevation myocardial infarction, significant bleeding, or other serious procedural complications, patients undergoing PCI can be discharged after an appropriate monitoring period, provided they are hemodynamically stable, and all comorbidities are stable. 

The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Pharmacy/Prescription drugs

Diagnosis: Ulcerative colitis
Treatment: Infliximab (Renflexis)
The insurer denied infliximab (Renflexis). The health plan's determination is upheld. 

This patient is a female with a history of severe ulcerative colitis. She was started on corticosteroids and started to improve. Her diarrhea frequency is improved, and her appetite is better.

Renflexis (infliximab) is not medically necessary for this patient.

Infliximab (Renflexis) is Food and Drug Administration (FDA) approved for treatment of pediatric ulcerative colitis. However, the clinical practice guidelines recommend using corticosteroids as a first line treatment for induction of remission. If a patient sees improvement on corticosteroids, then mesalamine products and/or immune modulators (such as azathioprine) can be added and the corticosteroids can be weaned off.

Per the same guidelines: "If disease is still chronically active or frequent flares despite adequate thiopurine treatment, consider infliximab".

There is evidence supporting the early use of infliximab in acute severe colitis for induction if corticosteroids fail to induce remission. In this case, the patient was started on corticosteroids and has reported improvement in stool frequency and abdominal pain. It is reasonable to continue induction with corticosteroids and add a mesalamine medication and/or an immune modulator as recommended by the practice guidelines.

This child is not hospitalized with severe acute colitis and has not failed to respond to corticosteroids. Therefore, at this point, Renflexis is not medically necessary. The plan's alternatives are available and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Quadriplegic cerebral palsy.

Treatment: Occupational Therapy - OT - Individual Session in the home, per visit Increase to 3 visit(s) per week.

The insurer denied coverage for Occupational Therapy - OT - Individual Session in the home, per visit Increase to 3 visit(s) per week.

The denial is upheld. 

This is a female patient with quadriplegic cerebral palsy.  She has been receiving Occupational Therapy (OT) services 3 times/week. She also receives left upper extremity Botox injections for better control of her motorized wheelchair.  Treatment includes use of heating pad, soft tissue mobilization/range of motion and upper extremity exercises.  Currently under review is the medical necessity of occupational therapy-OT individual sessions at home, per visit increase to 3 visits/week.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the request for Occupational Therapy - OT - Individual Session in the home, per visit Increase to 3 visit(s) per week for an additional 6 months, if not indefinitely is not medically necessary.  The patient's diagnosis is quadriplegic cerebral palsy.  The patient also has a home health aide.  She remains non-ambulatory and requires maximal assistance of another person to perform transfer activities and bed mobility.  The maintenance treatment can be adequately performed by the patient's aide.  Continued (3 times/week) OT is unlikely to result in significant functional improvement and is not medically necessary.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, occupational therapy-OT individual sessions at home, per visit increase to 3 visits/week is not medically necessary.

The medical necessity for Occupational Therapy - OT - Individual Session in the home, per visit Increase to 3 visit(s) per week is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, GERD, Lumbar Spinal Stenosis and Diabetes Mellitus. 
Treatment: Increase Personal Care Services to 24 Hours per Day 7 Days per Week
(Live-In), 91 hours per week. 

The insurer denied the Increase Personal Care Services to 24 Hours per Day 7
Days per Week (Live-In), 91 hours per week. 
The denial is upheld. 

The patient is a female with a history of hypertension, GERD (gastroesophageal 
reflux disease), lumbar spinal stenosis and diabetes mellitus. Due to impairments 
related to these conditions, she requires assistance for the completion of the 
majority of her activities of daily living (ADLs). An appeal review was requested for 
potential approval of 24 Hours per Day 7 Days per Week (Live-In) Personal 
Assistance Services to offer increased ADL (activities of daily living) support. 

No, the proposed treatment of 24 Hours per Day 7 Days per Week (Live-In) 
Personal Assistance Services is not deemed medically necessary. 

The grievance/appeal statement and advocacy report state that the patient can no 
longer live alone due to progressive cognitive impairment and overnight fall risk. 
However, an assessment of the patient's functionality and ability to perform ADLs 
(activities of daily living) was completed and revealed that the 
currently approved plan of 56 hours per week Personal Assistance Services is
sufficient to meet the patient's current needs. 

Specifically, the assessment revealed that the patient is alert and oriented to place, 
person and time. She is using prepackaged medications on a daily basis with 
reminders provided by her aide. She has a bedside commode for use during 
overnight hours when her aide is not present for safety. Furthermore, there is no 
evidence of a medical medication which supports the need for overnight frequent 
toileting. An increase in personal assistance hours cannot be granted for safety 
supervision alone. 

There is no additional documentation which demonstrates that the patient has
sustained further functional loss since the date of this last assessment. For these 
reasons, the proposed treatment 24 Hours per Day 7 Days per Week (live-in) 
Personal Assistance Services is not deemed medically necessary.