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

Diagnosis: Dizziness and giddiness, hypertension, weakness, pain, tremor, diabetes, and chronic pain. 
Treatment: Increase Home Health Care (HHC)/Personal Care Level II Per 15 Minutes to 49 Hour(s) per Week. 

The insurer denied: Increase Home Health Care (HHC)/Personal Care Level II Per 15 Minutes to 49 Hour(s) per Week. 

The denial is overturned. 

This elderly female patient has medical conditions including dizziness and giddiness, hypertension, weakness, pain, tremor, diabetes, and chronic pain. She is appealing denial of increase home care/personal care to 49 hours per week. The health plan approved 35 hours per week. 

Uniform Assessment System (UAS) evaluation completed recently shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing medications, stairs, transportation, and lower body dressing; limited assistance with managing finances, phone use, personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. She has frequent bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed 3 years prior, there has been a decline with meal preparation, walking, and locomotion. 

The proposed treatment is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. She is appealing the denial of an increase in home care/personal care to 49 hours per week. The request was denied based on the Uniform Assessment System (UAS) evaluations showing minimally decreased functioning to now needing limited assistance with locomotion, walking, and phone use. Her activities of daily living have not changed overall. The health plan approved 35 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires assistance with all activities of daily living, except bed mobility and eating. Compared to Uniform Assessment System (UAS) evaluation completed 3 years prior, there has been a decline with meal preparation, walking, and locomotion. The patient has significant impairment in daily functioning. Uniform Assessment System (UAS) evaluations show the patient's functional status has declined. The approved personal care at 35 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care. 

The proposed personal care of 49 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervicalgia 

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is an adult with a history of asthma, Crohn's disease, gastroesophageal reflux disease, and hypertension. The patient presented to the hospital and had neck surgery to address cervicalgia and cervical spondylosis with myelopathy. Status post fusion cervical anterior with instrumentation; anterior cervical discectomy and fusion cervical (C) 5-6 with allograft/plate fixation and local bone graft. The patient received pain management and prophylactic antibiotics post-operatively and physical therapy.

The medical records demonstrate a non-complicated procedure. This patient underwent a single level anterior cervical discectomy. There was 25 cubic centimeters (cc) blood loss, and a drain was placed. The patient's vital signs were stable. The patient was able to tolerate oral medications. The patient reported no hoarseness and felt well. The recommendations included "DC (discharge) planning" and the drain was removed. The patient was evaluated by Physical Therapy (PT) on the same day and was found to be independent and able to walk 150 feet without support. The patient's pain was controlled. The recommendation was to take Tylenol as needed. The report of sore throat was noted with intravenous Decadron recommended. 

The post-surgical course was satisfactory without need for additional acute care. No additional consultations nor treatments were required. The patient did not need imaging or additional studies.

There were no problems nor bleeding from the surgical site. There were no extenuating circumstances to substantiate the acute admission and length of stay.

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

Diagnosis: Central Nervous System/Neuromuscular Disorder/Headache/abnormal computer tomography angiography of head and neck
Treatment: Inpatient Hospital Services

The patient is a man with a history of subarachnoid hemorrhage who presented to the emergency room with a severe headache. The patient had a computed tomography angiography (CTA) of the head and neck that suggested a possible vertebrobasilar artery dissection. The patient was admitted to the hospital for further studies. A magnetic resonance imaging (MRI) of the brain and a magnetic resonance angiography (MRA) of the head and neck were performed. The patient had no acute findings on the MRI of the brain and the MRA of the head and neck did not show a definite dissection. Neurology was consulted and recommended treatment with Aspirin 81 milligrams (mg) daily. An outpatient follow up was recommended. The patient was treated for his headache.
At issue is the medical necessity for the inpatient hospital services.

The health plan's determination of medical necessity is upheld, in whole.

No. The requested acute inpatient hospital services were not medically necessary.
The patient presented to the hospital with a severe headache. The patient was initially suspected of having a vertebrobasilar artery dissection; however, this finding was not confirmed on MRA of the head and neck. As such, there were no acute interventions other than treatment of the patient's headache. This level of service does not rise to an acute inpatient admission. The patient did not have an acute stroke. The patient did not require anticoagulation or thrombectomy for a stroke. He did not have a cardiac arrhythmia that required immediate intervention. The patient did not have a significant neurologic deficit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Surgical wound infection
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
The medical records show the patient has a complex medical condition. He had recently undergone a hip replacement. He has an open wound with purulence. There was great concern for underlying deep infection.  This could result in a catastrophic complication. 

His physician opened the entire previous incision [15 centimeter (cm)] and performed the irrigation debridement with closure. His physician placed a Vacuum-assisted closure (VAC) dressing with suction. Intravenous antibiotics were provided. Cultures were pending. It would be extremely important to monitor the wound for additional problems. It would be necessary to await culture report for definitive antibiotic use. 

Based upon extent of condition and post operative services, the admission and length of stay was appropriate.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hip surgery (procedure code 11044) and full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male with a past medical history of stroke and newly diagnosed atrial fibrillation. He was admitted to the hospital after implantation of a watchman device. During the hospitalization, he remained hemodynamically stable and there were no postprocedural complications. He was ultimately discharged the next day with outpatient follow-up with his cardiologist.

The proposed treatment is not medically necessary.

This patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. He did not have any procedural complications including anesthesia related issues or access site bleeding. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Painful left shoulder
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This is an adult female patient with a painful left shoulder. She was diagnosed with osteoarthritis. She underwent a total shoulder arthroplasty. She was admitted to the hospital on the next day.

The proposed treatment was medically necessary.

The records show a complex orthopedic procedure was completed requiring a drain. The post-surgical records show drainage and the need to monitor the amount. The records also show continued pain with the need for intramuscular (IM) Toradol. These services could not be provided as an outpatient. The records show concern and inpatient admission recommended.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male with chronic obstructive pulmonary disease (COPD), hypertension (HTN), gastroesophageal reflux disease (GERD), and diabetes mellitus (DM) who presented to emergency room with shortness of breath (SOB). The patient was found to have chronic obstructive pulmonary disease (COPD) exacerbation in the emergency room. The patient received multiple nebulization treatment as well as intravenous steroids. The patient continued to have pulmonary symptoms and was admitted to acute in hospital level of care. The patient was started on oral prednisone as well as duonebs on the medical floor at the time of admission. From admission to discharge, the patient continued to receive oral prednisone as well as duonebs. The patient had persistent shortness of breath / dyspnea on exertion (SOB/DOE) that did not improve significantly and took longer time to improve during the hospitalization. The requested acute in hospital admission is denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment is not medically necessary.

The patient was admitted with chronic obstructive pulmonary disease (COPD) exacerbation and was treated with oral prednisone as well as duonebs. During the hospitalization, the patient was hemodynamically stable. The patient was not on supplemental oxygen. The patient was tolerating oral diet. The provided treatment could have been safely and effectively be provided at a lower level of care. The requested hospitalization is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a patient with a history of hypertension and hyperlipidemia who presented to the emergency department (ED) complaining of chest pain and shortness of breath for 1 day that occurred at rest. A chest x-ray (CXR) was clear. An electrocardiogram (ECG) showed normal sinus rhythm (NSR) without ischemic changes. The patient was admitted to the telemetry service for evaluation of chest pain and rule out acute coronary syndrome (ACS). An echocardiogram showed mild to moderate mitral regurgitation (MR), normal cardiac function and normal wall motion. A stress test was performed and was normal. Telemetry monitoring showed NSR with occasional premature ventricular contractions (PVCs). The patient was discharged home after ruling out for ACS and completing an ischemic evaluation. At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary for evaluation of chest pain in this case given that the patient presented with atypical chest pain symptoms, low risk HEART [history, electrocardiogram, age, risk factors, troponin] score, negative cardiac troponins, and non-ischemic electrocardiogram (ECG).

This patient presented with atypical chest pain which had resolved prior to coming to the ED, the cardiac troponins were negative and there were no ischemic changes on the presenting ECG. The patient's HEART score was calculated to be 3, low risk for short-term risk of major adverse cardiac events (MACE) events. The patient completed an ischemic evaluation which was negative. Given the patient's atypical symptoms, low risk HEART score, negative cardiac troponins, nonischemic ECG, an inpatient level of care was not medically necessary. A lower level of care for evaluation of chest pain and rule out acute coronary syndrome (ACS) was medically appropriate and safe and supported by peer reviewed medical literature and expert consensus guidelines on patient's presenting the ED with acute chest pain (1-4).

A lower level of care would have been medically appropriate and safe in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea/vomiting
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay. 
The health plan's determination is overturned. 

This case involves a female who was seen in the emergency department (ED) with intractable nausea and vomiting for 2 to 3 days. The patient drinks daily alcohol and had the last intake of alcohol on the morning of the presentation. The patient has known alcoholic cirrhosis with a history of spontaneous bacterial peritonitis (SBP). Vital signs appeared fairly stable, with a blood pressure of 165/89, a temperature of 37, and a pulse rate of 77. On examination, the patient had no pedal edema and was not in any respiratory distress. Laboratory studies revealed stable hemoglobin, slightly low platelets of 112, and creatinine of 1.37 (baseline creatinine 1.2). The patient's potassium was quite low at 2.9.

The patient was admitted with an alcoholic gastritis diagnosis and acute kidney injury on top of chronic kidney disease. 

The inpatient hospital admission was medically necessary.

This is a complex case of a patient with daily alcohol use, a history of alcohol withdrawal, and concurrent high doses of methadone use, who presents to the hospital with nausea and vomiting for two days, severe hypokalemia, and prolonged QTc (interval) on electrocardiogram (EKG). This patient is at potential risk for severe cardiac arrhythmias and sudden cardiac death due to torsade. The echocardiogram reveals a decrease in the ejection fraction, further increasing the risk of cardiac arrhythmias. It was reasonable to monitor the patient in the hospital on continuous telemetry. It was also reasonable to perform a cardiac assessment before discharge. Based on alcohol abuse alone, the patient was experiencing tremors and had a CIWA (Clinical Institute Withdrawal Assessment) Scale of 12, indicating moderate to severe alcohol withdrawal symptoms. The patient's condition is a high risk when combined with a history of alcohol withdrawal from previous admissions, as documented in the medical record. It cannot be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Inpatient hospital services
The insurer denied the inpatient hospital services.
The health plan's determination is upheld.

The patient is a female who presented to the emergency department complaining of light headedness, palpitations, dyspnea and left-sided chest pain. Her medical history was remarkable for paroxysmal atrial fibrillation, hypertension, hyperlipidemia, diabetes, morbid obesity and mild to moderate mitral stenosis and regurgitation. She also has a history of heart failure with a left ventricular ejection fraction of 46 to 50 percent (%). The patient also has a history of breast cancer. Her blood pressure was 122/68 millimeters of mercury (mmHg) with a heart rate of 117 beats per minute. Her room air oxygen saturation was 96 percent (%). An electrocardiogram showed atrial fibrillation with a ventricular rate of 115 beats per minute and there were no acute ischemic changes. Her serum troponin level was normal. The patient's chest x-ray showed pulmonary vascular congestion. Her chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. There was mild interstitial edema. The patient was treated with a dose of intravenous Metoprolol followed by an oral dose. She was admitted to the hospital. Oral Metoprolol and intravenous Furosemide were prescribed. She remained in atrial fibrillation with ventricular rates ranging from 98 to 128 beats per minute. Per the progress note, the patient was expected to undergo a transesophageal echocardiography and electrical cardioversion. However, the procedure was delayed due to scheduling issues. It was performed and the patient's rhythm was successfully converted to sinus. She was discharged the following day.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. The patient presented with acute atrial fibrillation (AF). She was hemodynamically stable and there was no evidence of acute ischemia.

She was in mild decompensated heart failure, however she did not have high risk features such as hyponatremia, acute kidney injury or a significant troponin elevation. For stable patients presenting with acute AF, the safety of an alternate level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, low molecular weight Heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." Finally, based on the documentation provided it does not appear as if there was a medical reason for the delay in cardioversion. From a medical standpoint, when the patient's AF persisted cardioversion could have been performed then, with subsequent discharge after a full recovery from anesthesia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Female Infertility
Treatment: In vitro fertilization (IVF) cycle
The health plan denied the IVF cycle as not medically necessary.
The health plan's determination is upheld.

The patient is a female who has a euploid embryo and is seeking to use a gestational carrier. At issue is the medical necessity of another in vitro fertilization (IVF) cycle to create additional embryos.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of IVF cycle is not medically necessary for this patient. The patient has a euploid embryo which should yield at least a 50% (percent) chance of pregnancy for the treatment of infertility. Thus, at this time, additional embryos are not medically necessary for a reasonable chance of yielding a child.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent Pregnancy Loss
Treatment: Injectable medications for use in an in vitro fertilization (IVF) cycle
The insurer denied injectable medications for use in an IVF cycle.
The determination is upheld.

The patient has recurrent pregnancy loss, has a euploid embryo, and is preparing to use a gestational carrier. At issue is the medical necessity of injectable medications for use in an in vitro fertilization (IVF) cycle in this clinical scenario.

As the patient has a euploid embryo that has a 50 percent (%) plus (+) chance of a successful pregnancy, it is not medically necessary to do a stimulation cycle to create additional embryos at this time for the treatment of recurrent pregnancy loss/infertility. According to Pirtea, et al, live birth rates after a third frozen embryo transfer with a euploid embryo is 54.1% per transfer. Thus, this is appropriate treatment for infertility. Therefore, no additional stimulation for IVF is necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior Crossbite
Treatment: Braces (Comprehensive Orthodontic Treatment)
The insurer denied:  Braces (Comprehensive Orthodontic Treatment)
The denial is: Overturned

The patient is a female with an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity. The subject under review is the medical necessity for braces (comprehensive orthodontic treatment).

The health plan's determination is overturned.

The requested treatment is medically necessary.
This patient presents with an anterior crossbite on tooth 10, as well as moderate crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3
If left untreated the damage that will likely occur to the patients teeth will be much more time consuming and complicated to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.