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

Diagnosis: Central nervous system
Treatment: Home health Care
The insurer denied the increase in Home health care
The health plan's determination of medical necessity is overturned in whole. 

The increase in PCA is medically necessary for this patient. The patient has a past medical history of dementia and frequent falls with noted worsening of both conditions over the period of time between assessments.  PCP noted that the patient was having progression of dementia. More recently the provider that cared for the patient during a rehabilitation stay noted that the patient had poor insight, limited perceptions and poor judgment due to dementia, putting the patient at risk for injury as patient is impulsive with  actions, getting up from a seated position and walking without the walker. Due to  dementia patient is not able to remember proper technique to use a walker and needs to have reminder by aide staff to use the device correctly. For walking and locomotion the patient requires at least maximal assistance according to written documentation in both assessments performed. The patient has noted worsening of urinary incontinence on the most recent assessment tool and does take high doses of diuretic therapy due to congestive heart failure and severe mitral regurgitation, causing frequent visits to the bathroom and/or frequent need for incontinence cares. Documentation would support the patient would need at least maximal assistance to get to the bathroom without fall or injury. 24-hour PCA services would not be solely for supervision as the patient requires assistance and prompting with ADL's outside of the hours when the PCA services are allotted. In addition, the patient has a documented escalation of delusions and hallucinations. There is a need for proper prompting for locomotion and walking if patient ambulates in the night due to delusional thinking. (Patient gets up to check on the man that the patient believes is in the house, or to call  son in the night during these delusional/hallucination episodes).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, congestive heart failure (CHF), peripheral vascular disease, gait ataxia
Issue under review: Personal Care Services, Level II, 24 Hours per Day, Seven Days per Week (Split-Shift), for a Total of 168 Hours per Week
The insurer denied the Personal Care Services, Level II, 24 Hours per Day, Seven Days per Week (Split-Shift), for a Total of 168 Hours per Week.
The denial is overturned. 

Yes, the proposed treatment of an increase in Personal Care Services, Level II, 24 Hours per Day, Seven Days per Week (Split-Shift) for a Total of 168 Hours per Week is deemed medically necessary. 

The patient is a female with a history of hypertension, congestive heart failure (CHF), peripheral vascular disease and gait ataxia. 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 requested for potential approval of an increase in Personal Care Services, Level II, 24 Hours per Day, Seven Days per Week (Split-Shift) for a Total of 168 Hours per Week for increased assistance with completion of the patient's ADLs.

This is a female with a history of hypertension, congestive heart failure, peripheral vascular disease and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that the patient has sustained progressive functional decline with the development of pressure ulcers and worsening gait ataxia with recent fall injuries. Documentation from the patient's case manager indicates that the patient requires overnight assistance with bed mobility, transfers and toileting due to functional limitations. For these reasons, the currently approved plan of seven hours per day, seven days per week for a total of 49 hours per week is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in Personal Care Services, Level II, 24 Hours per Day, Seven Days per Week (Split-Shift) for a Total of 168 Hours per Week is deemed medically necessary for increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Services (CDPAS) for 24 hours per day (split-shift)
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS) for 24 hours per day (split-shift).
The denial is overturned. 

The patient is a female with a history of dementia. Due to impairments from her dementia, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of Consumer Directed Personal Assistance Services (CDPAS) for 24 hours per day (split-shift) to offer improved ADL assistance. 

Yes, the proposed treatment of Consumer Directed Personal Assistance Services (CDPAS) for 24 hours per day (split-shift) is deemed medically necessary. 

This is a woman with a history of dementia. Due to impairments from her dementia, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from multiple medical providers caring for the patient indicate that there is evidence of progressive functional decline due to the patient's dementia, Crohn's colitis and gait ataxia. The documentation also indicates that the patient is no longer independent in performing any of her ADLs including toileting, dressing, exhibits frequent wandering behavior, is a constant fall and safety risk and has issues with chronic diarrhea/dehydration.  For these reasons, the currently approved plan of 24 hours/day live in Consumer Directed Personal Assistance Services (CDPAS) is insufficient to meet the patient's current needs. Hence, the proposed treatment of Consumer Directed Personal Assistance Services (CDPAS) for 24 hours per day (split-shift) is deemed medically necessary to offer increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertebral compression fracture with non-displaced fracture

Treatment: Inpatient hospital service

The insurer is denied coverage for inpatient hospital service. The denial is upheld. 

This was then a female with a past medical history of hypertension, diabetes and alcoholic liver disease who presented to Emergency Department (ED). The patient had slipped, hitting her head and landing on her back. The patient reported a second episode of slipping to the ground while entering her car. In the ED, the patient was found to have a laceration to the back of her head with associated bruising to her back and her left knee. The patient's computed tomography (CT) scan report indicated a L1 vertebral compression fracture with non-displaced fracture to spinous prices at T12. There were also reported nondisplaced fractures to her ribs. The patient was admitted to the hospital and the Trauma/Orthopedic services were consulted. The patient's treatment was to use a brace and take pain medications. Incentive spirometer and physical therapy was prescribed. The patient was medically stable for discharge.

Based on the review of the medical record, the patient had several fractures status post the fall that required timely imaging and orthopedic evaluation. Imaging was completed, consultations were performed, and the patient was fitted with a brace. Progress note noted that the patient was "breathing well, pain controlled and can be downgraded." The patient's vital signs were stable, and there was no need for additional imaging or other treatments. The patient was able to tolerate oral pain medications, and had no other medical conditions that required inpatient management. The patient could have been safely treated at observation level of care because there was a high likelihood of improvement within 24-48 hours. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

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

Diagnosis: HTN (hypertension), dyslipidemia, diabetes, CAD (coronary artery disease)
Issue under review: Repatha
The insurer denied the Repatha. 
The denial is upheld. 

No, the treatment with Repatha is not medically necessary.

The patient is a male with a past medical history of hypertension, dyslipidemia, diabetes and coronary artery disease, status post (s/p) multiple percutaneous coronary interventions (PCIs). The patient has been treated with a combination of Repatha, low dose Rosuvastatin ten milligrams (MG) and fenofibrate. His low density lipoprotein (LDL) level on the most recent testing was 44 MG per deciliter (dL) (on therapy). The lipid panel (prior to initiation of Repatha) shows an LDL level of 50 MG/dL. As per attached letter, the patient was previously treated with rosuvastatin 10MG and 20MG doses and atorvastatin. No side effects from statin therapy or therapeutic failure was reported in the medical records provided. The coverage for Repatha was denied as there was no documented LDL level of 100 MG/dL or higher on maximally tolerated statin therapy. 

REPATHA is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C). 

The patient in this specific case has a history of atherosclerotic heart disease, as documented by cardiac catheterization, and therefore requires control of lipid levels. Use of high intensity statin medications is considered first line and a standard of care, and the use of proprotein convertase subtilisin/kexin type nine (PCSK-9) inhibitors, such as REPATHA are reserved for patients, in whom the LDL levels cannot be controlled with the maximally tolerated statin therapy or intolerance or contraindication to statin therapy. There was no indication in the medical records provided for review that the patient was intolerant of statin therapy, had significant side effects, or could not tolerate a higher dose. Also there was no indication that the patient's LDL levels were uncontrolled with the use of statin, prior to initiation of REPATHA. Therefore the medical necessity of REPATHA in this case is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive system /gastrointestinal Abdominal/stomach pain 
Treatment: Inpatient Hospital
The insurer denied the inpatient hospital stay. 
The denial is Overturned in whole. 

Summary:
This  patient, at the time of admission, with a 1-week history of subjective fever and intermittent epigastric abdominal pain. The patient presented to the emergency room (ER) with stable vital signs, appeared to be in moderate distress, curled up on bed and complaining of abdominal pain. 
The requested health service/treatment of inpatient hospital stay was medically necessary for this patient. This patient presented with abdominal pain and vomiting. the patient was found to be monospot positive and the  clinical presentation and history correlated with the diagnosis of mononucleosis. EBV is treated symptomatically and usually does not require admission but this patient had intractable emesis that did not respond to IV anti-emetics and aggressive IVF resuscitation. Decision to admit was made after 9 hours in the ER. The patient  was given time to respond to ER management but notes document that the patient failed a PO trial twice. Due to his PO intolerance and unresponsiveness to IV Zofran,  met criteria for inpatient level of care. The patient  demonstrated an inability to maintain oral hydration that persisted after ER management and observation care treatment.
This patient was held and observed in the ER for 9 hours and was unable to tolerate oral hydration. The patient  demonstrated an inability to maintain oral hydration that persisted after ER management and observation care treatment. Due to the  PO intolerance and unresponsiveness to IV Zofran, the patient met criteria for inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: overturned in whole

The patient is a female who presented to the emergency department (ED) with a complaint of lower back pain for 1 week. The patient denies specific injury or trauma but has been active in gym class and playing basketball and soccer. The pain begins over the right back and travels down the anterior thigh. Pain scale is rated 5/10 on the left and 9/10 on the right. The is unable to sit up, can walk with assistance.
ED vitals were temperature (T) 36.8 Celsius (C), heart rate (HR) 107, respiratory rate (RR) 22, blood pressure (BP) 153/87, and oxygen (O2) saturation of 100% on room air. Physical exam is notable for absent left patellar reflex, inability to single leg raise left lower extremity (LLE), limited single leg raise right lower extremity (RLE) due to pain. There was also pain to direct palpation of the thoracic and lumbar spine. Complete blood count (CBC) and electrolytes were normal; x-rays of the lumbar spine and hips were unremarkable. Given the physical exam findings and normal x-rays, the patient was admitted for spine magnetic resonance imaging (MRI) due to concern of radiculopathy. MRI of the spine showed nonspecific bone marrow edema of the L3-L4 facet joints and L4 pedicle, indicative of stress reaction. Pain was controlled with intravenous (IV) Toradol which was transitioned to ibuprofen for discharge. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned, in whole.

Yes, the requested inpatient stay was considered medically necessary.
This patient presented with acute back pain that was significantly limiting daily activities, causing an inability to sit and walk independently. According to the references cited, back pain in patient's that leads to activity limitations and seeking medical care is highly likely to be due to underlying pathology. Differential diagnosis for a patient of this age and presentation includes tumor, herniated disk, fracture, and inflammatory disease. Given this patient's severe movement limitations on presentation to the ED, pain requiring IV medications, and lack of diagnosis with ED care, this patient required inpatient admission for continued treatment and diagnostics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental health/suicide 
Treatment: Mental health /inpatient  
The insurer denied Continuing Mental Health Inpatient Facility Admission
The  denial is upheld in whole .


The patient with request for continuing inpatient mental health level of care.
The patient was admitted  due to a suicide attempt by ingesting 80 tabs of 200 milligram(mg)of Ibuprofen.
 No, the requested service of continuing mental health inpatient facility admission, is not medically necessary the patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. There were no medication changes. The patient had a safety plan.  There was no indication for around the clock monitoring.  Also, per Dulcan (2015) and Lewandowski RE1 (2013), treatment in the least restricted environment is the most appropriate for adolescent depression. Treatment could have been addressed at a lower level of care. The requested inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/Metabolic/Nutritional
Inpatient Hospital

The patient is a male with hx (history) of R (right) knee arthritis who presented to the emergency department (ED) with increased thirst, increased urination, vomiting, diarrhea and generalized. On presentation, vital signs were temperature 98.3, heart rate 84, blood pressure 124/ 80, respiratory rate 18, and pulse ox 100%. Physical exam was unremarkable with no significant abnormalities. He was admitted with DKA.

The health plan's determination is overturned. The acute inpatient admission is warranted for management of this patient's diabetic ketoacidosis (DKA). The patient was admitted for acute management of DKA which requires significant nursing and physician attention. He required insulin therapy, nothing by mouth (NPO) with monitoring of vomiting, frequent lab checks and adjustment of insulin regimen to ensure his ketoacidosis and hyperglycemia is resolving, frequent monitoring of clinical status and hydration status. Management at a lower level of care has the potential to be fatal.
According to Milliman Care Guidelines (MCG) criteria, patients must present with hyperglycemia, ketonemia (BHB greater than 3 and acidosis warranted acute inpatient management. However as noted in the MCG criteria (footnote C) in the presence of vomiting, ketoacidosis may be masked due to metabolic alkalosis secondary to vomiting, thus the AG of 19 is more indicative of his acidosis than acute pH on VBG.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male whose inpatient admission is under review. The patient presented with elbow wound (refused lab work) and sent home. An x-ray during the workup showed pneumonia. The patient was called back to the ER and he came the same day. He had drainage from a left elbow wound, known to be MSSA (methicillin-sensitive Staphylococcus aureus) bacteremia, increasing drainage from the wound. He also had fatigue.

In the ER, the patient's vitals were as follows: T (temperature) 97.6, P (pulse) 105, RR (respiration rate) 20, BP (blood pressure) 112/76. On general examination, the patient was NAD (no acute distress). The examination of the patient's chest and abdomen were normal. Examination of the patient's CVS (cardiovascular system) revealed him to be tachycardic. Examination of his skin revealed left elbow with post-op incision site with open wound and some drainage on the dressings.

The patient's labs were as follows: WBC (white blood count) 14.92 (high), Hg (hemoglobin) 11.7, Hct (hematocrit) 34.0, Plt (platelets) 422 (high), Na (sodium) 128 (low), K (potassium) 4.6, Cl (chloride) 92 (low), CO2 (carbon dioxide) 20 (low), BUN (blood urea nitrogen) 6, Cr (creatinine) 0.7, Glu (glucose) 198 (high), Lactic acid 5.1 (high)

Chest x-ray revealed patchy right lower lobe infiltrate. Left elbow x-ray revealed olecranon spur and bursitis, there may be a small amount of air adjacent to this spur. Infection with a gas-forming organism is raised.

After ER evaluation, the patient was admitted with sepsis (possible sources including elbow, bacteremia, and pneumonia). IV vancomycin and Zosyn were started. The patient left AMA (against medical advice) shortly after admission.

The patient meets initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1) as well as standard of care for multiple reasons, some of which are listed below:

1) Evidence of systemic signs of infection (tachycardia, leucocytosis, and lactic acidosis). 2) Concern for deep infection in the elbow. 3) Concurrent infection of the elbow and pneumonia. 4) Failure of outpatient therapy (worsening signs and symptoms despite previous surgical care). 5) Recent history of MSSA bacteremia with sepsis, and thus would need to rule out recurrent bacteremia/endocarditis with inpatient evaluation.

Thus, this admission was warranted, supported by standard of care and IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis 
Treatment: Inpatient admission 

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

This patient is a male who presented to the Emergency Department with abdominal pain and diarrhea. The patient was afebrile, and the patient's vital signs were stable. The patient's abdominal exam was benign. The patient's computed tomography (CT) scan revealed colitis. The patient was started on Cipro and Flagyl antibiotics, and the patient's symptoms improved. 

Based on the MCG (M-170) guidelines for inpatient admission for gastroenteritis, this patient did not meet the clinical criteria for inpatient admission. As per MCG guidelines, patients who meet the clinical criteria for inpatient admission are those who have suspected severe infection, such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, severe vomiting, and severe dehydration. 

However, based on the review of this patient's medical record, this patient's clinical signs and symptoms associated with the gastroenteritis were responsive to antibiotics. The patient's symptoms improved with antibiotics. The patient had received intravenous (IV) antibiotics (Cipro and Flagyl), hydration, Pepcid, and Reglan as inpatient. However, these treatments could have been provided at a less intensive level of care, such as observation. 

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

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.