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

Diagnosis:  Inability to walk.
Treatment:  Continued Skilled Nursing Facility.
 
The insurer denied the Continued Skilled Nursing Facility.  The denial is upheld. 

The patient is a male. The patient has a history of schizophrenia.  He was living in the community with his mother at baseline, independent for ambulation with a walker and requiring assist for activities of daily living.  He had a home health aide 4 hours a day, 5 days a week.

The patient was hospitalized due to inability to walk, with frequent falls at home for a few months.  It was noted that his mother was currently at a nursing home for rehabilitation.  He was diagnosed with a urinary tract infection.

Three days after admission, the patient was transferred to a skilled nursing facility for further care.  He was noted to have an indwelling urinary catheter.  He was on a regular consistency oral diet.  On therapy evaluations, he was dependent for all self-care.

Approximately a month later, the patient was requiring max assist for dressing and total assist for toileting.  He was unable to stand for activities of daily living.  He was noted to be making slow functional gains.  He had hearing and memory deficits, with occasional confusion.  He had a Foley catheter.

The patient was dependent for transfers.  He was non-ambulatory.

A month later the patient was dependent for dressing and max assist for toileting.

The patient was dependent for transfers.  He was non-ambulatory.

The patient was using a Foley catheter and was dependent for bowel care.  He was incontinent and using an incontinence brief.

The patient was max assist for bed mobility.

No, the Continued Skilled Nursing Facility was not medically necessary.

The patient has chronic self-care and mobility impairments.  He has schizophrenia and was living with his mother at baseline.  At baseline, he was using a walker and receiving assistance for his activities of daily living, including formal home health aide assistance.  He deteriorated in the community while his mother was in a nursing home for rehabilitation.  He was hospitalized briefly then was transferred to a skilled nursing facility.  He was not making substantial functional progress at the skilled nursing facility despite multiple weeks of therapy.  He remained essentially dependent for his self-care and mobility.  Cognitive deficits were a barrier to progress.  His care was custodial in nature and not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizures.
Treatment:  Inpatient hospital admission.

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

This is a female patient with a past medical history of asthma.  The patient presented to the Emergency Department (ED) with concerns for a seizure.  The patient reported episodes of eye fluttering/twitching, feeling lightheaded, and weak and dropping things lasting for seconds at a time.  The patient had this multiple times, but over the past 24 hours, the patient reported that this event occurred much more frequently.  The patient reported also a left-sided headache.  The patient reported often having migraines in the past.  The patient denied a family history of seizures.  The patient stated that she had been binge drinking and smoking marijuana, and stopped alcohol 3 weeks prior to the evaluation suddenly.  The patient borrowed 3 tablets of Xanax from a friend to relieve her anxiety.  The patient had a long history of psychiatric issues including anxiety, depression, borderline personality trait, self-mutilation by cutting, and 8 years of alcohol abuse with episodes of binge drinking and blacking out.  The patient's electrocardiogram (EKG) revealed normal sinus rhythm.  There was a witnessed episode of eye twitching and the patient was sitting up in bed with her eye twitching and intermittently not responding although she was sitting up and maintaining torso and arm control during the episode.  At the end of the assessment, the patient had a full tonic-clonic seizure, left arm straight and right arm crossed over the body, with foaming at the mouth.  This self-resolved within 2 minutes.  The patient's urine drug screen revealed an alcohol level of 17 and it was also positive for marijuana. The patient was discussed with the neurologist who recommended Keppra.  The patient was admitted to internal medicine for further monitoring, work-up, and care.  The patient's electroencephalogram (EEG) was performed and was normal. The patient's computed tomography (CT) scan of the head was normal. 

Based on the review of the medical record and literature, the patient developed a new onset of seizure with normal neurological examination, normal EEG, and normal head CT scan.  According to the patient's records, there was no clear evidence of an acute change in the patient neurological examination suggestive of acute stroke.  No acute motor, sensory or visual deficit that suggest an acute stroke.  There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute, prolonged metabolic decompensation or prolonged seizure.  Therefore, due to these clinical findings, the acute inpatient care admission was not medically necessary for this patient.

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

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

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

The patient is a female who presented to the emergency department complaining of non-exertional left-sided chest pain. Her medical history was remarkable for diabetes, hypertension and hyperlipidemia. Her blood pressure was 139/75 millimeters of mercury (mmHg) with a heart rate of 78 beats/minute. Her room air oxygen saturation was 98%. Her physical exam was remarkable for obesity. Her cardiac exam was normal. An electrocardiogram showed sinus rhythm with nonspecific T wave abnormalities. Her serum troponin level was normal and remained normal when repeated. She was treated with aspirin and nitroglycerin without relief and was admitted to the hospital to rule out acute coronary syndrome. She continued to have intermittent chest pain and had some relief with nitroglycerin. She was seen by a cardiologist who recommended myocardial perfusion imaging. This was performed and showed no evidence of ischemia. An echocardiogram showed abnormal left ventricular relaxation and was otherwise unremarkable.  Due to persistent complaints of chest pain, coronary angiography was performed and showed normal coronary arteries. The patient was seen by a gastroenterologist who recommended a barium swallow study. This showed grossly normal esophageal motility and no evidence of gastroesophageal reflux. The patient was discharged.

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

This patient, with multiple cardiac risk factors, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with the American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Home Health Care. 
The insurer has denied increase in personal care level 2 services to a total of 15 hours per week. 
The denial is upheld.

The patient is a male with a past medical history significant for coronary artery disease, benign prostatic hypertrophy with neurogenic bladder, irritable bowel syndrome, hypertension and osteoarthritis.
There is a request for personal care level 2 services 3 hours per day 5 days a week for a total of 15 hours per week. The additional services are being requested due to need for help with bathing and walking outdoors due to dizziness.
The patient is currently approved for 3 hours per day 4 days a week for a total of 12 hours a week. Additional services were denied based upon lack of medical necessity.
The subject under review is the medical necessity for the additional hours.

The health plan's determination is upheld in whole.

No, the requested health service is not medically necessary for this patient. The patient is a male with a medical history as listed above. His health plan denied the services based upon lack of medical necessity stating the following: Patient requires set up help for personal hygiene, toilet use and eating. He requires limited assistance for dressing upper body and lower body, bed mobility, walking, locomotion, bathing and toilet transfer. Patient needs extensive assistance for medication management. He requires maximal assistance for meal preparation. Time was noted to be allotted for meal preparation, laundry and housework. Patient is receiving social daycare in-home services and meals 2 days a week as a supplement due to physically not attending social daycare.
Uniform Assessment System (UAS) State of New York reports were reviewed for both dates provided.  Based upon information provided, the service hours currently provided are adequate to meet the patient's needs. Additional service hours are not medically necessary. Patient is currently receiving services 4 days a week 3 hours a day. The current number of hours are noted to meet his medical requirements as noted through the UAS and clinical testing tools. There is not a significant change from the tasking tool or the UAS from the first assessment time to the second. The patient does receive services at in-home daycare 2 times a week in supplement to his other clinical services because the patient cannot go out to daycare services due to Covid. Additional services above those as listed would be considered for safety or supervision and not typically a covered item under the plan without a concurrent medically necessary activities of daily living (ADL) or Instrumental activities of daily living (IADL) being provided. Additional personal care services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I,  vertical growth pattern, Class II canines, maxillary crowding, and posterior and anterior crossbite right mandibular canine).

Treatment: D8080 braces and D8670 monthly visits x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visits x 12.

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I,  vertical growth pattern, Class II canines, maxillary crowding, and posterior and anterior crossbite right mandibular canine. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 24 points on review by their internal reviewers. 

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care the HLD index is utilized. This index provides 6 specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet the insurer and the plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining a score of 24 points (4 overjet, 3 overbite, 10 anterior crowding, 3 labiolingual spread, and 4 posterior unilateral crossbite).

D8080 braces and D8670 monthly visits x 12 are not considered medically necessary for this patient.

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 D8080 braces and D8670 monthly visits x 12 is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right renal colic  
Issue under review: Inpatient admission  

Determination: The denial was upheld.  

The patient is an adult female. She was admitted with right renal colic of three days duration.  

The patient's vitals were 97.8-112/76-61-16.  The WBC (white blood cell) count was 6900.  The creatinine was 0.7.  CT imaging demonstrated a 9 mm right distal ureteral calculus with hydronephrosis.  A 6 mm left non-obstructing renal calculus was also present.  Pain medications, nausea medications, and IVF were administered.   On the same day, a bilateral ureteroscopy, laser lithotripsy and stent placement were performed.  

On the same day, the patient was clinically improved and discharged home.  She was afebrile and hemodynamically stable throughout the stay.  

An acute inpatient level of care was not medically necessary.  The patient's care could have been provided at a lower level of care.  She was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  She did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery.  She did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by bilateral ureteroscopy, laser lithotripsy and stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures 
Treatment: Inpatient hospital 

This is the case of a male with past medical history of seizure disorder who presented to the emergency department with a chief complaint of a witnessed seizure. The patient noted he had not taken his Keppra that day. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient with a known history of seizure disorder who presented to the emergency department with a witnessed seizure in the setting of having missed his Keppra. He was hemodynamically stable on presentation and noted to be post-ictal without other focal neurologic deficits or significant laboratory abnormalities. After Keppra loading in the emergency department, he had no further seizures and recommendation from neurology was to continue his home medication. This patient who presented post-ictal in the setting of seizure and medication non-compliance did not require inpatient care in the absence of prolonged post-ictal state, other neurologic deficits, repeated seizures, hemodynamic instability, or other acute medical issue requiring inpatient care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with a past medical history of anxiety, kidney stones and an ovarian cyst who presented to the Emergency Room (ER) with complaints of feeling a sharp, intense and persistent periumbilical abdominal pain, as well as nausea and near syncope. She was continuing to move her bowels. She was afebrile and her vital signs were stable. There was no abdominal rebound or guarding. A computerized axial tomography (CAT) scan showed borderline caliber of the appendix but not an acute appendicitis. She was treated with antibiotics. She felt better and the pain resolved.

Milliman Care Guidelines (MCG) clinical indications for admission for undiagnosed abdominal pain include hemodynamic instability, peritoneal signs, bacteremia, and the need for a procedure that cannot be performed on an outpatient basis. The patient did not have these conditions.

MCG clinical indications for admission for Gastroenterology include having an acute intra-abdominal process. This can be manifested by hemodynamic instability, peritoneal signs, bowel obstruction, or mesenteric ischemia. The patient did not have these conditions.

This patient had right lower quadrant (RLQ) abdominal pain but not an acute abdomen. No surgical interventions were needed. Intravenous (IV) hydration and pain management could have been given in the ER. If antibiotics were felt to be necessary, they could have been given orally as an outpatient. She did not meet MCG Criteria for inpatient care for either undiagnosed abdominal pain or gastroenterology. 

The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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

Diagnosis: Abdominal pain and Metastatic cancer.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient who had a history of cervical cancer with liver metastases who presented to the hospital with abdominal pain.  On a previous admission she was found to have a partial small bowel obstruction.  She was afebrile and her vital signs were stable.  There was no abdominal rebound or guarding.  A computerized axial tomography (CAT) scan revealed enteritis but no bowel obstruction.  An ileus was also reported as well as multiple hepatic metastases.  The pain was felt to be related to metastatic cancer.  Later that day she asked to leave the hospital. 

According to Milliman Care Guidelines (MCG), the clinical indications for admission for undiagnosed abdominal pain include hemodynamic instability, peritoneal signs, inability to maintain oral hydration, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis.  The patient did not have these conditions.

This patient had advanced metastatic carcinoma.  She did not have intestinal obstruction during this admission.  She required pain management but was stable to have received this on an outpatient basis.  Intravenous (IV) hydration could have been given in the Emergency Room (ER) with Observation status.  There was no evidence of sepsis.  She did not meet MCG criteria for admission for undiagnosed abdominal pain.  

The healthcare plan acted reasonably and with sound medical judgment.  An inpatient admission was not medically necessary.  

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

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female with a past medical history significant for recently diagnosed diabetes mellitus type II and asthma who presented to the emergency department, with complaints of severe abdominal pain as well as painful hemorrhoids and severe constipation. When the patient was seen by the admitting physician, she was afebrile, blood pressure was 135/98, pulse rate 136 beats per minute (bpm), respiratory rate 20. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits except for dry oral mucosa. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft with mild tenderness to palpation. The rest of the exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 6.6, hemoglobin 14.0, hematocrit 42.1, platelets 304. Sodium was 131, potassium 4.5, chloride 96, bicarbonate 16, blood urea nitrogen (BUN) 17.9, creatinine 1.64. The initial glucose was over 700. Arterial blood gas (ABG) performed, revealed that pH was 7.387, partial pressure of carbon dioxide (PCO2) was 27.2, partial pressure of oxygen (PaO2) 111, bicarbonate 16. The urinalysis demonstrated a large amount of glucose, ketones.
The patient was admitted to the hospital with a diagnosis of diabetic ketoacidosis, hemorrhoids, hypophosphatemia, constipation, hypertension, and asthma. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole.

Based on the patient's presentation and results of the laboratory studies, this patient had diabetic ketoacidosis due to uncontrolled diabetes secondary to noncompliance with diabetic medications. Therefore, the admission to the hospital was essential to provide adequate treatment of diabetic ketoacidosis in a timely manner, also for the initiation of insulin therapy, and to assure adherence to treatment. The patient's presentation and results of the laboratory studies were consistent with diabetic ketoacidosis.
The most urgent goals for treating diabetic ketoacidosis are rapid intravascular volume repletion, correction of hyperglycemia and acidosis, and prevention of hypokalemia. Identification of precipitating factors is also important. Treatment should occur in intensive care settings because clinical and laboratory assessments are initially needed every hour or every other hour with appropriate adjustments in treatment.
In this particular case, it was obvious that the patient had demonstrated medical non-compliance with the treatment. Furthermore, she had never been treated with insulin injections and needed the teaching of insulin injection techniques.
Therefore, the most efficient way to provide care in a timely manner was the admission at the acute inpatient level of care.