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

Diagnosis: Heel pain
Treatment: MRI of the foot
The MRI of the foot was medically necessary.

The patient is a female. She has experienced plantar fasciitis for the past 6 1/2 years in her right foot.  She then began experiencing a similar condition in her left foot, and commenced physical therapy.  She received two corticosteroid injections into her left heel.  An MRI was performed a little over a year ago, which showed a partial tear of the plantar fascia. At that time, she opted for conservative care, which consisted of rest stretching.  She did this for several months and had an additional cortisone shot.  She then underwent a hip replacement and was told to refrain from any nonemergency surgery for six months.  She resumed physical therapy for the left foot and had 18 additional visits in conjunction with her hip physical therapy. Once her hip completely rehabilitated, she scheduled her foot surgery.

The patient had failed conservative care for about 13 months, including almost 40 visits of physical therapy, stretching, and three corticosteroid injections.  Surgery is now planned.  The MRI was necessary for preoperative planning.

The patient has under gone one year of conservative care and has surgery upcoming for her left heel.  As she has failed conservative care and has surgery planned, the MRI was necessary for preoperative planning.
Appeal type: Medical necessity
Decision: Upheld

Growth Hormone Deficiency
Pharmacy/Prescription Drugs

The patient is a female who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). She was born after 33 weeks of gestation and her birth weight was 3 lbs 11 oz. Her mother's height is 63 inches and father's height is 65 inches (mid parental height of 61.5+/-2''). Her mother was late in her puberty and reached menarche at age 16 years. Family history is significant for short stature on the father side of the family and her paternal grandmother is 4' 10'' tall and paternal uncle is 5' 2''. By history, she has always been small and growing at lower percentiles for height. Nutropin AQ is being requested and is under review. 

The health plan's determination is upheld. Nutropin AQ is not medically necessary. With the progression of puberty, this patient's growth has improved and she has grown 5.6 cm in 7.83 months which gives her a growth velocity of 8.6 cm per year, which is pubertal confirming the impression of familial short stature with constitutional delay. ISS is a heterogeneous condition and not all children with ISS will respond equally to GH treatment. The Pediatric Endocrine Society Guidelines for Growth Hormone and Insulin-Like Growth Factor-1 Treatment in Children and Adolescents recommend GH treatment for ISS on a case-by-case basis after assessment of physical and psychological burdens, and discussion of risks and benefits. As this patient's height has never been 2.25 SD below the mean for age, she does not qualify for GH treatment under the indication of ISS. Therefore, Nutropin AQ is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Colitis 

Treatment:  Inpatient hospital services

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

This patient is a male who presented to the Emergency Department with complaints of abdominal pain as well as diarrhea, and generalized weakness.  The patient reported that he may have eaten something that affected his stomach.  The documentation indicated that the patient did not have any significant past medical history.  Patient denied recent travel or sick contact.  On physical exam, the patient had generalized tenderness to palpation to the abdomen with no guarding but was alert and oriented.  The patient's vital signs revealed a temperature of 100.4 with a heart rate of 102 bpm.  The patient's blood pressure was 120/70, and oxygen saturation was 96% on room air. The physician recommended the patient undergo laboratory diagnostic studies.  The laboratory studies did not reveal any significant abnormalities.  The patient's chest x-ray also did not reveal any significant abnormalities.  The patient's blood was collected for blood culture, and patient was admitted for colitis. The patient was treated with intravenous fluids and antibiotics (Ciprofloxacin and Flagyl).  Gastroenterology (GI) service was consulted for patient's positive blood cultures, and as per GI recommendations, the patient's antibiotic regimen was unchanged and was continued with improvement in patient's symptoms.

This patient was admitted with a diagnosis of possible infectious diarrhea.  The patient showed no signs, symptoms, or laboratory data to suggest toxicity or criteria to warrant hospital admission rather than observation.  Literature indicates that patients who need hospitalization are those with the following signs and symptoms:  volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, co-morbidities such as HIV and diabetes (immunocompromised status), age >=65 years, recent hospitalization or antibiotics, pregnancy, or weight loss.  However, this patient had neither fever nor severe abdominal pain.  The patient's lab data showed no electrolyte discrepancy, acid/base derangement, or renal impairment that needed acute admission status.  The patient's treatment with hydration and clinical monitoring could have been provided in the ambulatory setting without jeopardizing the patient's well-being.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Back pain 
Treatment: Radiology Services 

The patient has had low back pain with radiating symptoms down the leg, intermittent dragging of the right foot, numbness of lateral thighs and numbness of toes for the last three years.  The examination indicates some patchy sensory loss in the leg but otherwise is normal.  The request is for a magnetic resonance imaging (MRI) of the lumbar spine.  The health plan's determination of medical necessity is upheld.  Per the American College of Radiology (ACR) appropriateness guidelines MRI imaging of the low back for chronic low back pain and radiculopathy is not advised unless the patient has failed conservative measures for at least 3 weeks first.  While the patient's appeal note indicates that the patient has already seen multiple specialists for low back pain (including the current provider twice before) and that the patient has undergone previous x-rays and treatment of low back, the medical notes submitted for review do not support this.  Only one progress note was sent with the records for review which does not support these claims.  The providers note states that this is the first time they have evaluated this patient.  The exam is normal other than some patchy sensory loss on leg without any red flag signs or symptoms.  The note does not indicate the patient has had any previous treatment for low back pain such as medication, exercise, therapy, etc., or that conservative management has failed.  Therefore, based on ACR appropriateness guidelines for low back pain, an MRI of lumbar spine is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Blindness secondary to diabetic retinopathy.
Treatment:  Consumer Directed Personal Assistance.
 
The insurer denied Consumer Directed Personal Assistance.  The health plan's determination is overturned.

The patient is a male with a past medical history significant for diabetes mellitus, hypertension, chronic kidney disease (CKD) and blindness secondary to diabetic retinopathy.  He is requesting consumer directed personal assistance.  There is not a specific number of hours the patient is requesting; however, on the tasking tool it is noted the patient required 18.3 hours a week.

The Consumer Directed Personal Assistance is medically necessary for this patient.  The Uniform Assessment System (UAS) State of New York documents medically necessary services.  The UAS summary recommends 18.3 hours per week.  There are some level 2 services such as personal hygiene noted.

The conditions that the patient has (diabetes, hypertension and diabetic retinopathy) are temporary.  Services include level 1 services along with some level 2 services, such as personal hygiene.  The patient is able to ambulate independently but does have trouble with other activities of daily living (ADL).  Services were denied stating that the patient's needs are short-term and being provided through home health care agency.  However, there is no documentation that the services are being provided through another agency.  This patient's needs appear to be more chronic in nature, which would require some sort of personal assistance at home.

Therefore, according to the UAS, the Consumer Directed Personal Assistance is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System / Gastrointestinal - Hemorrhoids.
Treatment:  Inpatient Hospital.

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

The patient is a male, who presented to the ER late in the evening with right upper quadrant pain that radiated through to his back.  He did report associated nausea.  The patient was noted to have right upper quadrant tenderness without an associated Murphy's sign.  Vitals demonstrated mild tachycardia but were otherwise within normal limits.  The patient had a white blood cell count (WBC) of 13.2 with normal liver function tests (LFTs).  An ultrasound of the gallbladder demonstrated associated sludge in the gallbladder.  The patient was hospitalized for further workup.  Later, the next day, the patient underwent a computed tomography (CT) scan, which demonstrated wall thickening and inflammatory changes in the cecum concerning for mass.  The patient underwent a HIDA scan, which was negative.  By day 3, the patient's pain was noted to be improving.  He was having bowel function.  Gastroenterology was consulted to perform a colonoscopy to visualize the area in question on the CT scan.  A colonoscopy was performed on hospital day 4, and the area of concern on the CT scan was found to be normal with visual inspection on colonoscopy.  The patient was found to have hemorrhoids.  The patient was discharged home.

The inpatient level of admission is not medically necessary for this patient.  The patient was demonstrated to not have acute cholecystitis based on the HIDA scan.  The patient did not have acute cholangitis or common duct obstruction.  The patient's CT scan imaging suggested a mass in the right colon.  The patient improved, and this workup could have been done at a lower level of care.  During the hospitalization the patient did not demonstrate significant vomiting, dehydration, hemodynamic instability, severe pain, signs of intestinal obstruction or peritonitis, or bacteremia.  The documentation does not suggest that the patient's care could not have been performed at a lower level care.  There is no evidence that a complicating event occurred during the hospitalization.  There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care.  The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female child. She presented to the ED via EMS with a previously-diagnosed RSV (respiratory syncytial virus) illness, for evaluation of possible seizure. Her eyes rolled back and she vomited. She continued to vomit en route to the ED. Upon arrival, she was alert and moving around. She had been seen by her primary care practitioner four days prior with cough and congestion, diagnosed at that time with RSV. The mother was giving nebulizers periodically for increased work of breathing. She developed difficulty breathing prior to her eyes rolling back. She also had fevers to 101. 

Vital signs in the ED included temperature 38.2, heart rate 184, and respiratory rate 43 with 93% saturation in room air. Examination was significant for mild respiratory distress with accessory muscle use and rales, congestion with rhinorrhea, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was significant for normal WBC count with 8% bands and 52% neutrophils, mild thrombocytosis with 441K platelets, and low normal CO2 (carbon dioxide) 20. Chest x-ray revealed prominent perihilar bronchovascular markings with no evidence of pneumonia. 

The patient was treated with a normal saline bolus as well as an albuterol treatment prior to admission to the general pediatric service. Admission orders included observation for possible seizure, anti-pyretics as needed, and supplemental oxygen to maintain saturations greater than 92%. She had fever overnight to 104.5 but no seizure activity. She was treated every six hours with ibuprofen. She had no oxygen requirement and was tolerating an age-appropriate diet. She was deemed stable for discharge to follow-up with her pediatrician.

No, the acute inpatient admission was not medically necessary for this child.

This young child presented to the ED with several-day history of respiratory symptoms (already diagnosed with RSV) and one-day history of increased work of breathing. She had a spell at home at a time when she was febrile followed by multiple episodes of vomiting that was concerning for febrile seizure. She recovered upon arrival to the ED, with no postictal period. She was admitted for overnight observation to monitor progression of her respiratory distress as well as to monitor for further spells. She remained stable, with no respiratory distress and no spells. 

While it was not unreasonable to monitor her overnight, she was overall hemodynamically stable with no oxygen requirement, no persistent vomiting or signs of dehydration, no neurologic symptoms, and no evidence of sepsis or impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right foot ankle pain
Treatment: L3000 - Custom foot inserts
The insurer denied the L3000 - Custom foot inserts.
The denial is upheld. 

The patient is a female.  She suffered an injury while wrestling.  Initial x-rays showed fracture of the first metatarsal.  After being in a boot for eight weeks she had no progression and an MRI was ordered.  There were findings consistent with CRPS (complex regional pain syndrome).  She underwent physical therapy but discontinued physical therapy for a lack of progression.  She had pain with activity 8 out of 10 at its worst.

With the use of stretching exercises, the patient had returned to sneakers and had returned to gym class.  Custom orthotics had been ordered.

No, the L3000 - Custom foot inserts were not medically necessary.

Custom orthotic therapy would not be indicated for this patient.  While the clinician notes "valgus foot structure", the patient's radiographic and MRI (magnetic resonance imaging) results note only findings consistent with CRPS (complex regional pain syndrome).  This is a condition that is not typically treated with custom orthotics.  No benefit would be expected from custom orthotic therapy.  The patient may benefit from over-the-counter accommodative orthoses first.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced dementia, gait ataxia.
Treatment:  Increase in consumer directed personal care assistance hours to seven days per week, 24 hours per day, live in.

The insurer denied the Increase in consumer directed personal care assistance hours to seven days per week, 24 hours per day, live in.  The denial is overturned.

The patient is a female with a history of cognitive impairment from advanced dementia and gait ataxia with associated frequent fall injuries.  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 an increase in Personal Assistance Services to seven days per week, 24 hours per day, live in to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services to seven days per week, 24 hours per day, live in is deemed medically necessary.  

Recent documentation was received from the patient's physician indicates that due to progressive functional decline, worsening dementia and gait ataxia, she is completely dependent and totally incapacitated.  Therefore, the currently approved plan of 61 hours/week Personal Assistance Services is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment of an increase in Personal Assistance Services to seven days per week, 24 hours per day, live in is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, congestive heart failure, gait ataxia 
Treatment: Increase in PCA service 12 hours/day, 7 days/week, 12 hours/day, 7 days/week (split-shift) for a total of 168 hours/week 

The insurer denied the increase in PCA service 12 hours/day, 7 days/week, 12 hours/day, 7 days/week (split-shift) for a total of 168 hours/week. The denial is overturned. 

The patient is a male with a history of dementia, congestive heart failure (CHF) and gait ataxia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in Personal Assistance Services to 12 hours/day, 7 days/week, 12 hours/day, 7 days/week (split-shift) for a total of 168 hours/week to offer increased ADL support. 

Yes, the proposed treatment of an increase in Personal Assistance Services to 12 hours/day, seven days/week, 12 hours/day, seven days/week (split-shift) for a total of 168 hours/week is deemed medically necessary. 

An in home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 10.5 hours/day, seven days/week, for a total of 73.5 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. However, the medical records including nursing notes indicate that the due to the patient's urinary incontinence, poor bed mobility and need for assistance with frequent turning/repositioning and toileting needs, he has continuous, unscheduled need for assistance. In addition, the patient's provider has also documented that it is vital to the patient's health that he be turned according to the established schedule and provided with incontinence care around the clock to provide skin breakdown/pressure ulcer development. Lastly, the patient resides with his elderly spouse who is unable to provide care due to her own health issues. For these reasons, the proposed treatment of an increase in Personal Assistance Services to 12 hours/day, seven days/week, 12 hours/day, seven days/week (split-shift) for a total of 168 hours/week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/circulatory problems; chest pain.
Treatment:  Inpatient hospital.

The insurer denied  the entire inpatient stay.  The denial is upheld in whole.

The patient was brought by Emergency Medical Services (EMS) to the emergency department (ED) with chest pain.  The patient described the chest pain as on and off for the last one week, 6/10 maximum intensity for few minutes, sharp in character, no radiation, denies shortness of breath, palpitations, runny nose, fever, and cough.

No, the requested health service/treatment of the inpatient hospital stay was not medically necessary for this patient.

The patient presented with atypical chest pain.  The patient had an extensive cardiac history, with low ejection fraction (EF) and coronary stent placement in the past.  However, the patient had normal troponin; his ECG did not reveal any ischemic changes. The echo revealed low EF; however, that was not a new finding; the patient had history of cardiomyopathy with decreased EF.

The patient did not have evidence of congestive heart failure (CHF) exacerbation, and he was treated with his usual medications with some adjustment.  The patient had an erythematous and swollen testicle.  There was initial treatment with antibiotics; however, the final impression was that the patient had chronic condition, and he will follow with urology as outpatient.

The level of care provided to this patient and the condition did not meet criteria for inpatient admission.  A lower level of care would be more appropriate.  Therefore, the inpatient stay was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital  with episodic epigastric abdominal pain. She had known cholelithiasis. At the time of presentation, the patient complained of severe right upper quadrant pain. She was without a fever and vital signs were normal. The abdominal exam identified right upper abdominal tenderness. The white blood cell count (WBC) count was 13.6 thousand (K). The complete metabolic panel identified normal serum transaminases. The bilirubin was normal. An ultrasound showed gallstones without gallbladder wall thickening or pericholecystic fluid. She was initially treated with intravenous (IV) fluid and IV antibiotics. A surgical consultation was obtained and a laparoscopic cholecystectomy was performed. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure. She did have hydrops of the gallbladder. The patient was started on a diet following surgery.
The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. The patient had stable vital signs. Pain was controlled. The diet was advanced.
The patient remained clinically stable and was discharged from the inpatient setting. At issue is the medical necessity of an inpatient stay.

No. An inpatient level of care was not medically necessary in this case. The patient is a healthy female who presented to the hospital with known cholelithiasis/cholecystitis. Her evaluation identified gallstones and gallbladder inflammation. She was hemodynamically stable at the time of presentation. A cholecystectomy was indicated based on the ED evaluation. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. A surgery consultation was obtained and laparoscopic cholecystectomy was performed without complication.
There is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level of care which would have provided for surgical consultation, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care.
Extended stay following cholecystectomy may be required in the setting of failure to achieve discharge status, systemic infection, care for comorbidities or complications of the procedure, or other condition that requires inpatient admission. In this case, none of these indications existed to justify an inpatient level of care.