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

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

The patient has a history of axillary hidradenitis. He was treated with excision and autograft to the right axilla. A wound vacuum-assisted closure (VAC) was placed for postoperative management. The wound VAC was removed. There was 50% (percent) loss of the skin graft. The loss was attributed to failure of the dressing. The VAC was functioning poorly or the telfa clear dressing was not effective. Further grafting at a later date was anticipated. The patient had an allograft. Dressings were removed. The plan was for autografting. The dressing was removed with 95% graft take.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary for this patient.
The patient could have been managed at a lower level of care.  The patient had surgery and a lower level of care would have been appropriate for pain management and routine postoperative nursing care (monitoring of post anesthesia vital signs, etc). According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care, observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable and could have been managed at a lower level of care than inpatient to confirm the patient was recovering as expected from skin graft surgery. The patient could also have been managed at a lower level of care for the remaining days, the majority of which were spent with a dressing in place (wound exams not performed) and receiving occupational therapy. Inpatient care is not required for occupational therapy or while waiting for dressing changes. Per MCG, 25th Edition, Burn Non-critical: Admission is indicated for 1 or more of the following: Full-thickness burn greater than 10% of body surface area; Any burn greater than 15% of body surface area; serious burn of hand, foot, genitals, face, or major joint; inhalation injury; Burn accompanied by other significant medical problems or injuries (eg, Altered mental status, arrhythmia, inability to maintain oral hydration, significant wound or fracture); Serious chemical burn; High-voltage (eg, 1000 volts or more) electrical burn; Circumferential burn; Pain management requiring inpatient care (eg, IV narcotics). He does not meet criteria for admission to a burn unit. The patient could have received daily dressing changes at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fluid overload. 
Treatment: Inpatient hospital admission. 

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

The patient had diabetes and was on dialysis and presented with altered mental status. His blood sugar was 45 and he improved when given glucose. He was afebrile and the vital signs were stable. His oxygen saturation was 99% (percent) on room air. There was no abdominal rebound or guarding. An abdominal ultrasound revealed a gallstone, but the HIDA (hepatobiliary iminodiacetic) acid scan was negative. There was no leukocytosis. He was diagnosed with fluid overload and treated with IV (intravenous) Lasix. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (MCG (Milliman Care Guidelines) M-555) include having acute cholecystitis as manifested by upper abdominal pain and systemic signs of infection. In this case, the patient had gallbladder disease but did not have acute cholecystitis. In addition, he did not have systemic signs of infection. A gallbladder calculus is also an indication for admission if there is hemodynamic instability, common bile duct obstruction, severe vomiting, severe dehydration, severe pain, or bacteremia. The patient did not have these conditions.

This patient had hypoglycemia that rapidly responded to treatment. He had fluid overload but had good oxygen levels and could have continued with dialysis and IV Lasix with observation care. He had gallbladder disease but did not have acute cholecystitis or meet MCG guidelines for admission for Gallbladder or Bile Duct Inflammation or Stone. 

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

The denial is upheld. 

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

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

Diagnosis: Left-sided body numbness and weakness. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a woman with a past medical history of systemic lupus erythematosus who was admitted due to left sided numbness, tingling and weakness for 40 minutes. This was preceded by a COVID vaccine administration. The stroke team was activated. The patient was noted to have a National Institute of Health stroke scale (NIHSS) of two due to left sided drift. 

The patient was admitted to telemetry with acute neurologic deficit. The orders included neurological checks every two hours. The computerized tomography (CT) perfusion and vessel imaging showed no acute pathology. The magnetic resonance imaging (MRI) of the brain was unremarkable. The physical therapy evaluation noted weakness in the left lower extremity and abnormal gait. A front wheeled walker was recommended. 

Yes, the proposed treatment, inpatient hospital admission was medically necessary. 

The patient was admitted with neurological deficit concerning for a stroke. Given neurological deficits which required close neurological checks, this could not have been done in the outpatient setting. Milliman Care Guidelines (MCG) recommends admission when stroke is suspected especially when findings on examination indicate neurological deficit. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The inpatient hospitalization was justified by the Milliman Care Guidelines (MCG). Frequent neurological checks were warranted because of suspected stroke. Furthermore, this could have represented a transient ischemic attack. Furthermore the risk of stroke in transient ischemic attack is 5.3 percent (%) after two days and given that the patient could still be a candidate for acute intervention, it was appropriate for her to be admitted.
Appeal type: Medical necessity
Decision: Upheld

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

This male patient presented to the emergency department complaining of three days of intermittent chest pain that was sometimes worsened with exertion. His medical history was remarkable for coronary artery disease, myocardial infarction, heart failure with reduced ejection fraction, paroxysmal atrial fibrillation, stroke and closure of a patent foramen ovale. His blood pressure was 124/92 millimeters of mercury (mmHg) with a heart rate of 80 beats/minute. His respiratory rate was 16/minute with a room air oxygen saturation of 97%. An electrocardiogram showed no acute changes and the patient's cardiac biomarkers were normal. He was admitted to the hospital to rule out acute coronary syndrome. He complained of chest pain that was reproduced with chest wall palpation. His serum troponin level remained normal. An echocardiogram showed a normal left ventricular ejection fraction with mid anteroseptal and apical akinesis.  Cardiac catheterization showed an in-stent restenosis in the mid left anterior descending coronary artery that was treated with cutting balloon angioplasty and a drug-eluting stent. There was nonobstructive disease in the left circumflex artery. The patient continued to complain of mild left-sided chest discomfort. He was discharged.

Medical necessity for an inpatient admission is at issue.
The health plan's determination is upheld.

Based on the documentation provided an inpatient level of care was not medically necessary. This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient level of care 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 current guidelines, including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. Moreover, based on the records provided for review it does not appear as if there was a medical reason for the delay in performing this patient's cardiac catheterization. Based on the available documentation it appears as if, from a medical standpoint, the patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth-Other-Headache in pregnancy.
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.

In this case, the patient is a female gravida(G)5 para(P)2 ectopic (0)2 surgery 2 who presented at 34 4/7 weeks gestation with complaints of headache. The patient reported that she had been admitted prior and left against medical advice (AMA). She had no improvement with Tylenol, Reglan, Benadryl, and morphine. The patient reported no prior head imaging. The patient reported the headache to be occipital and temporal. There were no vision changes or scotomata (loss of vision). The patient had no confusion, speech changes, clumsiness, facial or limb numbness. She had no headaches like this before and reported no headache. Fetal testing was reassuring with a reactive nonstress test (NST). She underwent workup for preeclampsia, but blood pressure was normal, and she had no hypertension. She underwent neurology consult and magnetic resonance angiography/venography (MRA/MRV) that was normal. She underwent an occipital nerve block and this improved and resolved the headache. The hemolysis, elevated liver enzymes, low platelet count (HELLP) labs were normal and negative for HELLP syndrome or preeclampsia.

Based upon a review of the medical records in this case and the care provided, the admission to acute inpatient level of care would not have been medically necessary at the acute inpatient level of care in this case. The patient was admitted for headache without neurological signs or acute findings on evaluation. The patient was noted to have a normal exam and report of headache. There was rendered imaging and an occipital nerve block which are both procedures that can be completed at a lower level of care and would not require admission to the acute inpatient level of care. The magnetic resonance imaging (MRI) /MRA/MRV in this case can be performed in a lower level of care setting. The patient would be able to receive monitoring, imaging, and pain management at a lower level of care. There were no indications for delivery of the fetus or surgical intervention for neurological emergency or cerebrovascular accident (CVA). This was not suspected based upon a normal neurological exam. The diagnostic testing of labs, imaging with MRI and ultrasound and pain management would be performed at the lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline.
Treatment: Home health care.
The insurer denied Personal Care Services, Level 2: 10 Hours per Day, 7 Days per Week (Total of 70 Hours per Week). 
The health plan's determination is overturned. 

The patient is a female with past medical history of age-related cognitive decline, depression, anxiety, hypertension, coronary artery disease, osteoporosis, osteoarthritis, insomnia, hearing loss, legal blindness, urinary incontinence, gastroesophageal reflux disease (GERD), hypothyroidism, atrial fibrillation on chronic anticoagulation, and congestive heart failure who had been assigned PCA (personal care assistant) services.

Personal Care Services, Level 2: 10 Hours per Day, 7 Days per Week (Total of 70 Hours per Week) are medically necessary for this patient.
The patient has documented functional and cognitive decline. The patient's primary care physician (PCP) documented medical necessity of increased PCA services. The patient had previously assigned PCA services 12 hours/day, 7 days/week before enrollment with current insurer. The patient requires assistance with all activities of daily living (ADL) / Instrumental activities of daily living (IADL). The insurer assumed the patient had informal help outside of the currently assigned PCA services. The request to increase PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, personal care services 10 hours/day, 7 days/week, to total 70 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Diazoxide. 
The denial is overturned.

The patient is a female with non-insulinoma pancreatogenous hypoglycemia. She has had recurrent hypoglycemia requiring intervention from family members. She has undergone a 72 hour fast, which confirmed hypoglycemia. Imaging has not revealed an intervenable source. She has tried and failed acarbose. Request for diazoxide is under review.

The health plan's determination is overturned.

This request is for diazoxide for the treatment of hypoglycemia. The prior request was denied as the patient has not tried and failed Gvoke. Gvoke is a form of glucagon and is a treatment for severe hypoglycemia. This patient has recurrent hypoglycemia and requires diazoxide to prevent hypoglycemia. Diazoxide functions by lowering insulin secretion. Gvoke is not an appropriate alternative as it does not lower insulin secretion and is only Food and Drug Administration (FDA)-approved for the treatment of severe hypoglycemia. Gvoke does not prevent hypoglycemia. Without diazoxide, this patient will be at ongoing risk of severe hypoglycemia, which can cause seizures and be life-threatening. Therefore, the requested diazoxide is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower lip swelling
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with a history of hypertension on antihypertensive therapy with Lisinopril. She was admitted for lower lip swelling and a concern for angioedema secondary to Lisinopril, which was the day prior to admission. She was thought to have angioedema without airway compromise secondary to the Lisinopril. She was initiated on intravenous corticosteroids, antihistamines and an H2 blocker with an improvement in symptoms the following day. 

An Inpatient Hospital Admission is not medically necessary for this patient.
Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary. This patient was admitted for lower lip swelling and a concern for angioedema secondary to Lisinopril, which was the day prior to admission. On the day of admission, the physician records state, the patient presented with lower lip swelling, she did not have tongue swelling, difficulty swallowing, throat tightness, difficulty breathing, itching or hives/rash. On physical exam, she was found to have a blood pressure of 129/71, respiratory rate of 18 breaths per minute, heart rate of 66 beats per minute, temperature 97.1 F (Fahrenheit) and oxygen saturation of 99% on room air. On exam, she had localized to the lower lip but no intraoral swelling, she was not in any respiratory distress with good air entry bilaterally and had no evidence of stridor or wheezing. In the emergency room, after administration of intravenous corticosteroids (dexamethasone), antihistamines (Benadryl) and an H2 blocker (Famotidine), the patient remained hemodynamically stable, had a patent airway without signs of requiring intubation and her laboratory work was unremarkable. She was kept on continuous oximetry monitoring and was breathing comfortable without signs or symptoms of airway compromise and improved back to baseline the following day. Therefore, the inpatient hospital admission was not medically necessary and the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission.

The denial is upheld.

The patient presented to the Emergency Department with complaints of shortness of breath (SOB), chest pain, cough, and wheezing that started four days prior. The patient had a history of asthma, end-stage renal disease, and hypertension. The patient had a fistula to right arm for which he receives dialysis. Review of systems was noted to be negative except for a positive cough, chest tightness and shortness of breath. He was also positive for chest pain, and leg swelling. Faint expiratory wheezing noted, as well as faint rales for lung sounds. The patient was hypertensive with a blood pressure of 172/79. His hemoglobin was noted to be 5.8. The patient noted he had maroon stools for the past month, takes iron pills, and he declined rectal examination, but was agreeable to blood transfusion. The patient was pending dialysis and a blood transfusion was in progress. The patient was under observation at this time. He was admitted to the hospital and the patient received one unit of packed red blood cells and was recommended for an additional unit, but the patient demanded to go home. The patient refused to stay and received treatment and eloped, left (against medical advice [AMA]).

The patient could have been managed at a lower level of care such as observational level for the blood transfusion, and even hemodialysis could have been set up for observational or outpatient to receive the hemodialysis and blood transfusion. The patient was stable, no acute bleeding was noted.

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 emergency admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carotid angioplasty. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This male with a history of a transient ischemic attack (TIA) was hospitalized for carotid angioplasty. He underwent elective, scheduled left carotid angiogram with left carotid stenting on the same day. His pertinent past medical history (PMH) is remarkable for smoking, a right carotid bruit and peripheral vascular disease (PVD) with claudication. The patient's vitals were stable. He tolerated the procedure well and was discharged to home the next day. 

This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient. 

No, the proposed inpatient hospital admission was not medically necessary. 

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria are not met, including there were no procedure complications, including stroke or other vascular complications requiring surgical care, symptomatic bradycardia requiring therapy, thromboembolic event, shock, cardiac arrest or major bleeding at vascular access site. The care the patient received, including for an uncomplicated carotid angiogram with stenting procedure, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment; Home health care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 55 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, hypertension, urinary incontinence, osteoporosis, chronic obstructive pulmonary disease (COPD), aortic stenosis, and osteoarthritis. 

Home Care / Personal Care HHC - Level 2 Personal Care Services: 55 Hours per Week are medically necessary for this patient.
There is documentation from the assessment that the patient has had increased assistance needs with tasks of dressing lower body, transfer toilet, toilet use, and bed mobility. Despite this change there was no significant increase in the amount of hours per week provided to the patient for Personal Care Aid (PCA) services. The patient has no informal help other than her son who is noted to work as a professor and is unable to provide continuous care outside of the hours of currently assigned PCA services. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient has no informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 55 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.