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

Diagnosis: Pain over Cholecystectomy Tube
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a past medical history (PMH) of cirrhosis, asthma, and recent cholecystectomy status/post (s/p) cholecystectomy (C)-tube who was admitted with complaints of (c/o) pain over the C-tube site s/p exchange and fever. The vital signs were unremarkable, but the patient did develop transient borderline low blood pressure (BP) 80-90s over 40-50s (80-90s/40-50s). The physical exam was notable for C-tube with site clean/dry/intact, positive (+) abdominal tenderness, blood in the bag. Lab work was notable for hemoglobin 5.8 (baseline 7-8), negative cultures. Imaging studies, a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no findings to suggest active extravasation. The patient was diagnosed with blood loss anemia and treated with 2 units of packed red blood cells (PRBCs) and antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o pain and subjective fever after C-tube exchange. The patient was found to have a slightly lower hemoglobin than baseline but had no history of hematochezia, hematemesis, or melena; there was documentation of blood in the bag after the C-tube exchange, but there were no additional episodes of bleeding during the hospital stay. The patient received two units of PRBCs and empiric antibiotics pending negative cultures, symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR)) or known coagulopathy. The patient did have transient borderline hypotension, which responded to fluids and the red blood cell (RBC) transfusion, and the hemoglobin remained stable after transfusion. This patient could have been safely observed and received diagnostic work-up, consultation and transfusion at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cholecystitis
Treatment: inpatient stay
The insurer denied the inpatient stay.
the health plan's determination is overturned. 

This patient is a female who presented to the emergency room (ER) with complaints of right upper quadrant (RUQ) abdominal pain in the setting of prior emergency department (ED) visits with known cholelithiasis. An upper gastrointestinal (UGI) series revealed cholelithiasis. The white blood cell count (WBC) was 6.9. Vital signs were stable. Pathology did confirm acute and chronic cholecystitis with cholelithiasis. However, the patient had severe persistent pain with history of multiple similar episodes in the past, requiring intravenous fluids (IVF), nothing by mouth (NPO), IV abx (antibiotics), and IV pain medication to improve pain. 

The inpatient hospital admission was medically necessary. The patient had severe RUQ which required IVF, IV abx, and IV pain medications. This was in the setting of some GB (gallbladder) thickening, no clear cholecystitis but a history of multiple prior attacks requiring ED visits. In general, elective cholecystectomy for simple biliary colic or cholelithiasis can be performed in an ambulatory or outpatient setting. Given the patient's history and findings of confirmation on pathology of acute on chronic cholecystitis, this patient required inpatient support to improve her symptoms with perioperative IV abx, prior to the decision to proceed with surgical cholecystectomy. The patient did meet medical necessity for inpatient admission with clinical suspicion of early acute cholecystitis which was confirmed on pathological evaluation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) from 32 hours to 37 hours per week.

The insurer denied an increase in Consumer Directed Personal Assistance Services (CDPAS) from 32 hours to 37 hours per week.  The health plan's determination is upheld.

This is a patient with a medical history notable for emphysema and shoulder pain. The patient is approved for 32 hours per week of consumer directed personal assistance services. The patient and her care team requested an increase to 37 hours per week, and this request was denied by the health plan.
A Uniform Assessment System (UAS) was completed. The patient lives in an apartment with her spouse. She has a medical history notable for chronic obstructive pulmonary disease (COPD), anxiety, depression, arthritis, chronic shoulder pain, urge incontinence, and hearing loss. The patient was alert and oriented and able to direct her own care. She was able to call for help in an emergency. For her instrumental activities of daily living, the patient requires total dependence for meal preparation and housework. She requires maximal assistance for stairs, shopping, and transportation. She requires extensive assistance for finances and medications. For her activities of daily living, the patient requires extensive assistance for bathing and dressing lower body. She requires limited assistance for walking, locomotion, toilet transfer, and toilet use. She is independent for all other domains. The patient has a slow and unsteady gait and ambulates by holding on to furniture as support. She uses a cane outdoors. She is occasionally incontinent of urine and is continent of stool. She uses pull-ups as needed for incontinence care. There was no fall in the previous 90 days. A task tool associated with the assessment recommended 32.08 hours per week to adjust the patient's personal care needs. Compared to a prior assessment, the patient showed a similar level of function. There were no medical records or letters of medical necessity provided as part of this appeal.
At issue is the medical necessity of an increase in Consumer Directed Personal Assistance Services (CDPAS) from 32 hours to 37 hours per week.

The requested health service has not been clearly demonstrated to be medically necessary for this patient.
There was no documentation provided regarding which personal care needs are not being met with the current allotment of personal care hours. The patient has some functional limitations as outlined in the assessment. The assessment task tool recommends 32 hours per week to address these needs. This is the number of hours that was granted by the plan. There is insufficient documentation provided regarding unmet care needs that would require the additional requested hours. Therefore, the requested increase has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient Hospital Stay.

The insurer denied inpatient hospital stay. The determination is upheld.

This is a female patient who was sent from urgent care to the emergency department (ED) to rule out deep vein thrombosis (DVT). She reported the afternoon prior, she began to feel malaise and abdominal discomfort and noted swelling and erythema of the right lower extremity (RLE) that worsened over the following hours. She reported feeling chills. In the ED, she was afebrile. An ultrasound (US) was negative for deep vein thrombosis (DVT). An electrocardiogram (EKG) showed normal sinus rhythm (NSR) and nonspecific conduction delay.

An x-ray of the RLE showed no bony abnormality or moderate soft tissue edema consistent with (c/w) cellulitis. Computed tomography (CT) RLE showed no occlusion.

Infectious disease (ID) was consulted for antibiotic therapy. Hematology/Oncology consulted for some noted enlarged lymph nodes R inguinal, iliac, and femoral. The antibiotics were changed to Cefazolin.

A gastroenterology (GI) consult was also obtained for a very mildly elevated aspartate aminotransferase (AST) that was felt likely due to her acute infection and to be monitored.

She remained afebrile and hemodynamically throughout her admission. She responded to treatment and was discharged on oral Keflex.

At issue is the medical necessity of an inpatient stay.

Based on the provided documentation, this patient could have been safely and appropriately treated at a lower level of care and then transitioned to outpatient care and follow-up.

This patient was admitted for RLE cellulitis. She did not have crepitus on the exam; there was no free air on the x-ray, her US was negative for DVT, and the x-ray was c/w cellulitis. She did not have findings concerning necrotizing cellulitis or necrotizing fasciitis. She had an initial leukocytosis with the left shift, consistent with her clinical findings, that normalized. She had a mild acute kidney injury that resolved quickly. She had an unremarkable renal US. She had some enlarged lymph nodes noted that likely were reactive from her acute cellulitis. She had a mild hyponatremia that resolved. She was seen by ID, and antibiotics were narrowed to Cefazolin. She remained afebrile, clinically and hemodynamically stable throughout her admission; she was awake, alert, and oriented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: possible seizure
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a young girl who has a history of strabismus and vitamin D deficiency. She was admitted through the emergency room with a 2-week history of abnormal head movements to the left, and an unusual feeling in her head, described in the notes as headache. She had seen an outside pediatric neurologist who did not think that the movements were infectious in origin. Initially, her family had observed head movements 2-3 times a day, but at the time of admission they were occurring every few seconds. She had also had throat clearing over the previous months.

The inpatient hospital admission was medically necessary.
The patient was admitted after having an explosive increase in frequency in abnormal head movements. Differential diagnosis included tics or seizures. Her history of being able to suppress the movements to some extent would be more consistent with the movements being tics. Tics do not typically occur during sleep, however, the father's description of seeing head and shoulder movements while she was sleeping raised concern for the events being seizures. An inpatient admission for video electroencephalogram (EEG) was medically necessary to capture the episodes for differential diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dental abscess
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a man with a history of hypertension and mental health problems. He presented to the emergency room with a two-day history of a right sided toothache radiating down to the left jaw, fever, and chills. Vital signs were notable for a temperature of 100.3 degrees, blood pressure 168/97, and pulse 116. He was alert and in no apparent distress. Physical exam revealed right sided lower molars with carious changes, erythema and swelling of the gingiva, tenderness to palpation of the floor of the mouth, and swelling below the right mandible. Labs showed a white blood cell (WBC) count 14,400, glucose 119, and creatinine 1.45. The neck computed tomography (CT) scan revealed a 2 centimeter (cm) abscess in the floor of the mouth. The patient was admitted for further evaluation and treatment.

The inpatient admission was not medically necessary for this patient.
Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, persistent hypoxia, or severe metabolic disarray. The decreased renal function did not require acute inpatient care. The services provided - antibiotics, hydration, oral medications, tooth extraction with abscess drainage - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease Exacerbation. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient has a history of chronic obstructive pulmonary disease (COPD), asthma, hypertension (HTN), and chronic kidney disease (CKD). The patient presented to the emergency department (ED) with complaints of shortness of breath and chest tightness.  The patient's vital signs at time of presentation were: temperature (T) 98.3 degrees Fahrenheit (F), heart rate (HR) 96, respiratory rate (RR) 22, blood pressure (BP) 190/110, and oxygen (O2) saturations 92 % on room air (RA). 

The patient was described to be in no acute distress. The patient had some decreased breath sounds and bilateral wheezes. The patient's abdomen was soft. The patient was alert and oriented (A x O) X 3 and had a non-focal neuro exam. The patient's white blood cell (WBC) count was 6.5. The patient's electrocardiogram (EKG) showed normal sinus rhythm with no acute ST or T wave changes. The chest x-ray (CXR) showed no acute infiltrates. 

The patient was treated with 60 milligrams (mg) intravenous (IV) Steroids, Magnesium, DuoNeb and also started on Azithromycin. The patient was admitted to the hospital with a COPD exacerbation. 

The patient remained stable after admission. As per the notes, the patient was in no acute distress and had no new complaints. The patient was being treated with IV steroids, inhaled Budesonide, and Breo Ellipta. The patient's vital signs were stable. This continued to the following day and steroid taper was started with plan to switch to oral (PO). 

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status for up to 48 hours while diagnostic testing and treatment were initiated. The patient had improved with treatment, was afebrile and hemodynamically stable. The patient was tolerating PO. The patient's O2 sats were normal at >90% on RA. This patient was stable to be switched to PO steroids and PO antibiotics if clinically indicated and the patient could have been discharged home on inhalers and other PO meds with close follow up in an outpatient setting. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: occipital neuralgia
Treatment: Pain Injection to Block the Occipital Nerve (x 1) 
The insurer denied Pain Injection to Block the Occipital Nerve (x 1) 
The health plan's determination is overturned. 

The patient is a female who is diagnosed with occipital neuralgia. The patient has previously tried and failed treatment with acetaminophen, nonsteroidal, anti-inflammatory drugs, corticosteroids, gabapentin, and cyclobenzaprine. These medications were largely ineffective. Her treating neurologist is requesting occipital nerve blocks for her neuralgia. 

The Pain Injection to Block the Occipital Nerve (x 1) is medically necessary for this patient. The patient is diagnosed with occipital neuralgia. Occipital nerve blocks are widely regarded by the neurologic community in pain community as both diagnostic and therapeutic for treatment of occipital neuralgia. Generally, it is recommended that a patient try and feel first line therapies. In this case, the patient has tried and failed multiple therapies for treatment of occipital neuralgia, including physical therapy, , nonsteroidal, anti-inflammatory drugs, corticosteroids, gabapentin, and cyclobenzaprine. All of these recommended therapies have not been effective. Therefore, the use of the occipital nerve blocks as a last line therapy is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: urethral stone
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a male with a history of hypertension (HTN), hyperlipidemia and kidney stones who presented with right sided abdominal pain that radiates to the right flank with associated nausea, vomiting, urgency, and dysuria of one day's duration. He denied chest pain, shortness of breath, fevers, chills, or hematuria.

The inpatient hospital admission was medically necessary in this case. The patient presented with acute onset of right flank pain. He was found to have bilateral ureteral stones and acute kidney injury. There was a reasonable clinical suspicion that he had bilateral ureteral obstruction which constitutes a urologic emergency and requires immediate intervention. Indeed, the concern of bilateral hydronephrosis was confirmed on cystoscopy and he require the placement of bilateral ureteral obstruction. He was at high risk for worsening acute kidney injury which can lead to respiratory distress, cardiac arrhythmias, severe electrolyte and metabolic abnormalities and death. It was necessary to admit him to an inpatient level of care to ensure that he received prompt urologic intervention and close monitoring of any complications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure.
treatment: Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

This case involves a male with a past medical history significant for hypertension, severely dilated thoracic aortic aneurysm with aortic regurgitation, obesity, and former smoker, who presented to the emergency department (ED) for evaluation of shortness of breath, chest pain, and abdominal pain. In the ED, the patient was hypertensive, blood pressure (BP) 168/94. Physical examination was notable for acute heart failure with significant lower extremity edema. 

The inpatient hospital admission was medically necessary. The patient presented with shortness of breath, chest pain, abdominal pain and was diagnosed with acute heart failure with volume overload along with severe thoracic aortic aneurysm. The patient required telemetry monitoring, serial lab assessment, IV (intravenous) diuresis and urgent evaluation and treatment of his large thoracic aortic aneurysm. For these reasons, he was not stable for discharge and was appropriately transferred for further inpatient treatment of acute heart failure with volume overload along with surgical evaluation for his large thoracic aortic aneurysm. Based on the patient's high level of medical complexity highlighted by acute heart failure and large thoracic aortic aneurysm with associated aortic regurgitation, the inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: peripheral artery disease 

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult female with a past medical history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), peripheral artery disease (PAD) status post multiple lower extremity (LE) endovascular interventions. The patient presented (2 months prior to admission) with complaints of cramping and tightness to the calf area. An ankle brachial index (ABI) study showed right 0.64, left 0.96. The patient denied lower extremity (LE) ulceration, skin discoloration and edema. 

The patient was referred for a peripheral angiogram which was completed during admission and included: distal aortogram with bilateral Iliofemoral runoff, selective right and left lower extremity angiogram, percutaneous transluminal angioplasty (PTA) and directional atherectomy drug-coated balloon (DCB) right superficial femoral artery (SFA) and Perclose (suture repair technique) of left femoral artery (LFA).

Per Milliman Care Guidelines (MCG) National Guidelines 27th Edition, the expected length of stay (LOS) for an angiogram and peripheral arterial intervention is ambulatory. 

In keeping with this expected length of stay (LOS), this patient could have been placed in Observation Care. The main indication for hospitalization, including monitoring for bleeding and thrombosis, all could have been performed safely, effectively, and efficiently as Observation Care, not requiring a 24-hour acute inpatient hospitalization. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inguinal Hernias
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is an infant with a previous history (Hx) of necrotizing enterocolitis (NEC) who was found to have inguinal hernias and presented for an elective laparoscopic inguinal hernia repair. The patient was admitted postoperatively. At issue is the medical necessity of an inpatient stay.
Inpatient admission was not medically necessary for this patient. Although the patient was premature and required observation following anesthesia, the patient did not meet criteria for a hospital admission. The patient could have been observed post anesthesia at a lower level of care for 24 hours prior to discharge given the lack of documented intraoperative or postoperative complications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder Pain
Treatment: Physical Therapy

The insurer denied physical therapy. The health plan's determination is upheld. 

This is a patient diagnosed with shoulder pain and cervicalgia. Records show a denial of a request for additional physical therapy visits.
Physical therapy notes showed that the patient had completed 38 sessions of physical therapy for the neck and right shoulder, reporting that her shoulder was feeling better overall with no increase in pain and less treatment. It was stated that flexion and abduction remain limited but continue to show gradual improvement while following protocol, though no actual physical examination findings were documented.

The requested Physical Therapy (PT) Visits/Services are not medically necessary for this patient.
Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home physical therapy (PT). Adhesive capsulitis: Medical treatment: 16 visits over 8 weeks. Post-surgical treatment: 24 visits over 14 weeks."

The patient is noted to have a history of chronic shoulder pain, and records provided showed that the patient had completed 38 sessions of physical therapy for the neck and right shoulder with no documentation of any objective improvements. The patient then subsequently underwent surgery. It was noted the patient was participating in physical therapy postoperatively. Still, there were only physician progress notes submitted, no physical therapy notes during that timeframe, and it is unknown how many physical therapy visits were completed following the surgery. It appears the patient has had an extensive amount of physical therapy well beyond the standard of care and no physical therapy notes outlining specific progress made based on objective measurements or standardized assessments. Additional physical therapy was not medically necessary.