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

Diagnosis:  fever, chills, low back pain, urinary frequency, headaches, and weakness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of back pain. She presented with six days of progressive fever, chills, low back pain, urinary frequency, headaches, and weakness.

The patient's Vital Signs were as follows: Temperature 99.5, Pulse 90, Respiratory Rate 20, Blood Pressure 100/60, Pulse oxygenation 98%. The patient's exam was remarkable for lumbar spine tenderness.

The patient's labs were as follows: White blood cells (WBC) 15.5, Hemoglobin/Hematocrit (H/H) 11.9/37.2, Platelet (Plt) 276, Sodium (Na) 131, Potassium (K) 4.6, Blood urea nitrogen/Creatinine (BUN/Cr) 6/.94, Glucose 99. Urinalysis (U/A) was positive for protein, blood, bacteria. Venous blood gas was 7.5/27.8/134/22. The patient was COVID negative. The patient was Strep and Legionella negative. Chest x-ray revealed no acute disease. EKG (electrocardiogram) revealed sinus tachycardia.

The patient was admitted with sepsis. Plan of care included empiric IV (intravenous) antibiotics.

On day three, the patient's vital signs were stable, and she was afebrile. ESR (erythrocyte sedimentation rate) was 106. CRP (C-reactive protein) was 28.3. Urine culture revealed Escherichia coli. The patient was noted to be clinically improving. The plan was for lumbar MRI (magnetic resonance imaging).

On day four, the patient's vital signs were stable. Blood cultures were negative. MRI (magnetic resonance imaging) was negative for osteomyelitis. The only source identified was urinary tract. The patient was switched to oral antics and cleared for discharge.

No, the Inpatient admission was not medically necessary.
This patient could have been safely and effectively treated at a lesser level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

This patient was admitted with suspected sepsis with suspected source being urinary tract. She was hemodynamically stable. She did not have bacteremia. She did not have altered mental status. Her renal function was normal. She had not failed an outpatient or observation level of care. The requested Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder-Kidney stones.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient is without a significant past medical history who presented to the hospital with 5 days of right lower quadrant pain. He was seen at an outside hospital and was told he had a kidney stone on a computed tomography (CT) scan and discharged on Flomax. His pain worsening brought him into the emergency room. He had multiple episodes of vomiting the day prior to presentation. He denied hematuria, flank pain, fevers, or chills. His pain was 8/10, constant and non-radiating.
Vital signs showed that he was afebrile with a blood pressure of 140/89, a pulse of 76, a respiratory rate of 16 and a room air pulse oximetry of 100% (per cent). On exam he was not in any acute distress, and he had right lower quadrant abdominal tenderness. Labs showed a creatinine of 1.39 and a white blood cell count (WBC) of 16.5. A urinalysis was not suggestive of a urinary tract infection. A CT scan of his abdomen and pelvis showed moderate right hydronephrosis and hydroureter to the level of a 3 millimeter (mm) right ureterovesical stone. Urology was consulted and felt that no acute intervention was needed. They recommended to continue Flomax, intravenous (IV) fluids and pain management. He was started on IV fluids; pain was controlled with IV morphine. He was discharged the next day in stable condition.

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with renal colic. He was hemodynamically stable. He did not have refractory pain, nausea or vomiting in the hospital. He did not have acute kidney injury. He did not have bilateral ureteral obstruction or unilateral obstruction of a solitary kidney. He did not require an inpatient urologic procedure. He did not have a complication from an outpatient procedure that required inpatient management. He did not have a documented complicated urinary tract infection or bacteremia. He could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a history of seizure disorder who presented after a seizure. At presentation her neurological examination and neuroimaging were normal. She was admitted and monitored on video EEG (electroencephalogram). She was started on Keppra and discharged to home.

No. The proposed treatment was not medically necessary.
The member, who had a known diagnosis of seizure disorder, presented after a spell at home, and at presentation was at her neurological baseline with normal vital signs and negative neuroimaging. There were no recurrent spells documented. The monitoring, treatment, and diagnostic studies could have been safely and effectively provided at a lower level of care.

Yes. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The patient's presentation was at her neurological baseline with normal vital signs and negative neuroimaging.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine fibroids.

Treatment: procedure code 58674, laparoscopy surgical ablation of uterine fibroids.

The insurer denied coverage for procedure code 58674, laparoscopy surgical ablation of uterine fibroids.

The denial is upheld.

This case involves a female who is seen regarding fibroids. She has been on hormones for control of bleeding; however, this has been ineffective. She does not want to undergo a hysterectomy; however, she is interested in treatment to reduce menstrual bleeding. The documentation does indicate she does have a history of anemia; however, current laboratory studies were within normal limits. She has had symptoms for greater than a year. She does not experience any pain and has been passing clots. Objectively, there was no significant findings. Treatment options were discussed, and the patient was wanting to proceed with a surgical ablation. An ultrasound provided for review does detail an enlarged uterus with multiple myomata distorting uterine contour.  

According to the referenced literature radiofrequency ablation may be indicated when there is evidence of a leiomyoma documented by imaging, the patient desires uterine conservation, the patient is premenopausal, and there is documentation of testing that has ruled out other potential causes and greater than 3 months of persistent symptoms that include abnormal uterine bleeding that has been unresponsive to conservative management, bowel dysfunction, painful intercourse, infertility, iron deficiency anemia, pelvic pain or pressure, and/or urinary dysfunction. The submitted documentation does not detail the above. The submitted documentation indicated per ultrasound there is evidence of fibroids. However, there is no documentation that she has undergone the appropriate screening given the provided biopsy recommended a repeat study be done for definitive diagnosis. The documentation also indicated per chart note it was recommended she undergo requested procedure in addition to a D&C (dilation and curettage). Given all of the above the prior determination remains upheld.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. The requested procedure has final approval from the appropriate regulatory bodies for this diagnosis. This patient is not a good candidate for ablation with imaging guidance for the treatment of uterine fibroids. Ablation with imaging guidance for the treatment of uterine fibroids is not best available treatment for this patient at this time. The adverse risks are not increased over standard treatment/services. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of procedure code 58674, laparoscopy surgical ablation of uterine fibroids should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied Dental plan-Crowns.
The denial is upheld. 

The patient is a male who presented to the office of his dental provider for evaluation and treatment of teeth number (#)s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31. Previous denials from the health plan have been on the basis that the number of teeth requiring restoration is in excess of the maximum allowed (3), and that the patient can be treated with a complete denture. The provider has planned treatment of porcelain ceramic crown for teeth #s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31, and mouthguard.
At issue is the medical necessity of Dental plan- Crowns for teeth numbers (#)s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31.

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

The requested health service/treatment of Dental plan- Crowns for teeth #s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 is not medically necessary for this patient.
Based on the provided documentation there is currently no evidence of medical necessity for the requested therapy. There is no clinical findings, diagnosis or periodontal charting documenting the need for treatment. Hence, treatment is not medically necessary in the absence of clinical findings and factors, nor diagnosis in support of the treatment.
Therefore, the requested health service/treatment of Dental plan- Crowns for teeth #s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 is not medically necessary.
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. She had been noted to have hyperglycemia and hypothyroidism. She has a history of goiter. She had a history of asthma, with her last attack 9 years ago. Her parents stopped her insulin and metformin 3 years ago as they thought it worsened her glucose control. Her medication for hypothyroidism was also stopped by the family. Ten days prior to admission, she sustained a head injury with concussion when she hit her head on a decoration on a carnival ride. She had no loss of consciousness or seizure activity. She described headache, blurred vision, sleep disturbance and unsteady gait.

The neurologist recommended treating the patient with 1 gram per kilogram (g/kg) intravenous immunoglobulin, given that she was symptomatic, had an abnormal neurological examination and evidence of active demyelination on MRI (there was contrast enhancement in the lesions in the cervical cord). Intravenous steroids were contraindicated given her hyperglycemia.
The patient was discharged home with follow-up arranged with an endocrinologist and multiple sclerosis specialist. Medications at discharge included metformin, Humalog insulin, Synthroid, nortriptyline for headache, and glucose monitoring supplies.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The requested inpatient stay was medically necessary for this patient.
The patient was admitted to the hospital for treatment of her hyperglycemia and hypothyroidism, together with her recently diagnosed central nervous system demyelination. She was symptomatic, complaining of headache, blurred vision, sleep disturbance and unsteady gait. Her neurological examination was abnormal, with ataxia as evidenced by a positive Romberg sign and inability to perform tandem gait. There were numerous T2 enhancing lesions consistent with demyelination throughout the brain and spinal cord. Of particular concern, there was evidence of active demyelination in the cervical cord, with contrast enhancement of the lesions. Untreated, demyelination in the cervical cord can result in paralysis, sensory impairment and loss of bowel and bladder control. Immediate diagnostic evaluation and treatment on an inpatient basis was necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

This male presented to the emergency department complaining of left flank pain, cough, and exertional dyspnea. His medical history was remarkable for hypertension, diabetes, and morbid obesity. His blood pressure was 221/111 millimeters of mercury (mmHg) with a heart rate of 96 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 100%. On physical exam he had clear lungs and left costovertebral angle tenderness. His electrocardiogram showed sinus rhythm without acute changes. His serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. The chest x-ray showed possible pulmonary vascular congestion. The urinalysis was unremarkable. The abdominal and pelvic computed tomography (CT) scan showed no evidence of renal stone. There was mild cardiomegaly and mild body wall anasarca. The patient was treated with morphine and intravenous fluid. His blood pressure was 169/88 mmHg after the morphine. At one point he was given supplemental oxygen for an arterial oxygen saturation of 91%.
He was admitted to the hospital with possible heart failure exacerbation. Intravenous furosemide was prescribed. An echocardiogram showed normal left ventricular systolic function and moderate left ventricular hypertrophy. Diastolic function was normal for the patient's age. The patient denied dyspnea but complained of pleuritic back pain. Chest CT angiography showed no evidence of pulmonary embolism. There was a minimal pericardial effusion. The patient's symptoms were thought to be due to viral bronchitis. He was discharged.
At issue is the medical necessity of Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
Based on the documentation provided an inpatient level of care was not medically necessary. This patient presented with dyspnea that was thought to possibly be due to decompensated heart failure. He was hemodynamically stable without high-risk features such as hypotension, ischemic electrocardiographic changes, marked BNP elevation, acute kidney injury or hyponatremia. Based on his Emergency Heart Failure Mortality Risk Grade score his 7-day mortality risk was low. In heart failure patients without high-risk features, studies have shown that a lower-level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, an inpatient admission was not medically necessary.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic lower back pain

Treatment: Inpatient stay

The insurer denied coverage for an inpatient stay

The denial is upheld 

Per clinical documentation, the patient was transferred to a hospital after a fall from a three-wheeled bike. The patient had repair of a scalp laceration at the hospital. The patient was noted to be intoxicated. The patient presented with pain and numbness of the right arm, neck pain, and headache. The patient did not recall any loss of consciousness and did not remember hitting their head. A C (cervical) collar remained in place. An x-ray of the femur noted a fracture of the enthesophyte of the left patella. A knee-immobilizer was placed. A CT (computed tomography) of the chest and abdomen was negative. The patient was evaluated by the trauma team, and it was noted that the patient would be admitted "for observation." An MRI (magnetic resonance imaging) of the neck was negative. Per MCG (Milliman Care Guidelines) general trauma and general admission criteria, hospital admission is indicated when patient with significant multiple trauma requires inpatient care for one or more of the following: major surgical and postprocedural care, nonoperative care of significant injury, or multiple trauma and one or more general admission criteria. [1, 2] Per provided clinical documentation, the patient did not undergo any surgical procedures. The patient did not meet any general admission criteria. Per provided clinical documentation, the inpatient admission was not medically necessary.

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

The insurer's denial of coverage for the inpatient stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hypothyroid, dementia, history of 2 strokes

Treatment   Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week  

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week  

The denial is overturned 

The patient is a woman with multiple medical problems including hypertension, hypothyroid and dementia.  She also has a history of 2 strokes.  The insurer approved Personal Care Aide (PCA) of 11 hours/week, 7 days/week for a total of 77 hours/week.  Under review is the request for PCA Level 2: 12 hours/day-7days/week (split shift)- for a total of 168 hours/week.

According to the Uniform Assessment System (UAS) report , the patient has significant cognitive deficits.  Cognitive skills are described as "severely impaired." She is oriented only to person and does not recognize caregivers or family members.  The patient is totally dependent for activities of daily living tasks that include personal hygiene, dressing and toilet use.  She is incontinent of bowel and bladder.  The patient is also totally dependent for bed mobility and is non-ambulatory.  She is bed bound, unable to feed or reposition herself.   The patient's severe dementia and progressive functional declined after a nearly 2-month hospitalization due to another stroke, this supports the medical necessity of personal care assistance (PCA) 24hours per day, 7 days per week split shift, to allow her to resume living safely at home.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

The requested increase Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is medically necessary for this patient.  

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

The insurer's denial of coverage for Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is the case of a male that presented to the emergency department with complaints of facial swelling. He does have a history of chronic ischemic cardiomyopathy (ICM) with an ejection fraction of 15% (percent).  He was status post diastolic heart failure (DHF) requiring admission 3 months prior. He did discontinue use of all heart failure (HF) medications approximately 1-week prior given concern for volume depletion. However, a few days prior he noticed scrotal swelling which then progressed to abdominal and facial swelling. He denied chest pain or shortness of breath. Per physical exam he had a blood pressure of 185/102. There is wheezing present. There is edema to the bilateral lower extremities. The physician recommended he undergo laboratory diagnostic studies in addition to a cardiology consult. The documentation indicated he was given intravenous (IV) Lasix. The documentation indicated he was admitted due to acute on chronic combined systolic and diastolic congestive heart failure fluid overload. He did have adequate urine output after being treated with IV Lasix. He was also recommended to undergo an ultrasound of the scrotum due to swelling. The study showed bilateral hydrocele and possible left chronic epididymitis. Urology was also consulted. He did undergo a urology consult which did not recommend any further genitourinary intervention. It was recommended however he follow-up once discharged. The documentation did indicate he continued with treatment and denied any further adverse events while hospitalized. He was discharged with instruction to follow-up.

Management of a patient with severe ischemic cardiomyopathy of 15% cannot be rushed, careful diuresis and management is critical, and an inpatient admission is required at times depending on the patient's clinical condition and avoiding swings from hypertensive urgency/emergency to hypotension can be lethal. An approach of treatment of such severe cardiomyopathy patients is discretionary to the cardiologist experience.

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.