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

Diagnosis: Sickle cell disease
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for asthma and sickle cell disease who came to the emergency department with complaints of pain all over his body. He was in his usual state of health till 3 days before the presentation.

The inpatient hospital admission was not medically necessary.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care.
The review of the medical records demonstrated the patient had no signs and symptoms involving the central nervous system as a result of the sickle cell crisis. There was no evidence that the patient had acute chest syndrome. The chest x-ray looked normal.
There was no mention of chest pain, hypoxemia, tachypnea, dyspnea, abnormal breath sounds, or hypoxemia. The patient's kidney function was completely normal, and mild hyponatremia improved within a short period of time. There was no evidence of acute ischemia, acute renal failure, aplastic crisis, priapism, or any vascular complications. This patient had mild pharyngitis, which was treated with oral antibiotics. There was no evidence of infection requiring inpatient treatment. The patient had normal mental status during the entire hospital stay. The pain control was achieved during a short period of time that was most consistent with the observation period. This patient had stable H&H (hemoglobin and hematocrit) levels and did not need an exchange transfusion. Taking into consideration all these facts, observation was appropriate.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male child. He presented to the ER (emergency room) with approximately 4 days of minimal to no food intake, significant decrease in oral fluid intake with the patient only taking water and no fever noted. The patient had seen the pediatrician prior to the ER (emergency room) visit, they were diagnosed with a viral syndrome and were told no emergency services were needed.

Upon evaluation in the ER (emergency room), the patient exhibited no signs of distress, no difficulty in waking, no fussiness, no diarrhea or vomiting or abdominal pain or inconsolable crying noted nor fever. The patient was noted to be non-toxic appearing with no symptoms of distress noted, and only abnormal exam findings were dry lips.  The vitals were evaluated and normal. The patient did not have a failed PO (per os - oral) challenge in the ER (emergency room) noted.

No, the Inpatient admission was not medically necessary.
Upon evaluation in the ER (emergency room), the patient exhibited no signs of distress, no difficulty in waking, no fussiness, no diarrhea or vomiting or abdominal pain or inconsolable crying noted nor fever. The patient was noted to be non-toxic appearing with no symptoms of distress noted, and only abnormal exam findings were dry lips.  The vitals were evaluated and normal, but that is not telling, as vitals (especially heart rate and blood pressure) can be normal until severe symptoms of dehydration (representing a loss of [greater than] > 10% (percent) of fluid) are present.  The patient did not have a failed PO (per os - oral) challenge in the ER (emergency room) noted. For mild and moderate dehydration, oral hydration is recommended by the AAP (American Academy of Pediatrics) and WHO (World Health Organization).

The patient had no documented symptoms showing distress or decompensation or an inability to take liquids by mouth.  Appropriate oral rehydration solutions such as Pedialyte, were attempted in the ER (emergency room).  The carbon dioxide was noted to be lower, at 14, where a level of 15 and above is preferred.  But with no symptoms of difficulty maintaining fluids (no diarrhea, vomiting) and an exam lacking signs of moderate/severe dehydration, as well as no other abnormalities noted on lab assessment, the admission was 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: Upheld

Diagnosis: Cold-immersion Injury/Trench Foot.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented after requesting assistance with case management. He was found to have trench foot.

The patient's vital signs were stable. The patient was afebrile. Exam showed dusky appearing feet, tender to palpation with some peeling. His CBC (complete blood count) and BMP (basic metabolic panel) were normal. He was admitted for supportive care.

No, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient was admitted after having presented with trench foot. The patient was hemodynamically stable and afebrile. He did not have evidence of infection. He was admitted for supportive care. The patient did not receive intervention that required an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness; near syncope
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He presented after developing dizziness and near syncope after working out. His vision became blurry, and he went to the ED (emergency department). He has history of hypertension, hyperlipidemia, PAF (paroxysmal atrial fibrillation), and nephrotic syndrome.

The patient's exam showed sinus tachycardia, and Code Stroke was called. The patient received CT (computed tomography) head, IVF (intravenous fluids), and neurology consult. He was admitted to telemetry, and he was monitored. MRI (magnetic resonance imaging) was ordered, as was echocardiogram.

No, the Inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this patient's case, the symptoms were atypical and unlikely to be representative of an acute stroke. All testing failed to reveal a pathologic condition requiring advance care. His treatment was IVF (intravenous fluid) and monitoring.

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care.

There was no "complex" care that required inpatient level of care in this patient. In fact, all tests showed absence of a pathologic condition that caused the presentation.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence that "observation care had failed or was inappropriate." Nor was there any evidence that the patient could not be managed safely at a lower level of care.

All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care. Thus, inpatient level of care was 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: Upheld

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


The patient has a history of medullary sponge kidney, frequent urinary tract infections (UTIs), endometriosis, Barrett's esophagus, Factor V Leiden and gut malrotation who presented for a urinary tract infection. She was see by her primary care physician and was given oral Bactrim but after only one dose she developed high fevers and presented with right flank pain, dysuria and urinary urgency. She was admitted for management of pyelonephritis. On presentation she has a temperature of 101.9 degrees Fahrenheit, a pulse of 112, a respiratory rate of 20, a blood pressure of 120/79, and a room air pulse oximetry of 100%. She was not in any acute distress and had right costovertebral tenderness. Her lab results showed a creatinine of 1.14, a blood urea nitrogen (BUN) of 8, a lactic acid of 1.1, and a white blood cell count (WBC) of 14.9. A urinalysis showed 21-50 WBCs, 11-20 red blood cells (RBCs), small leukocyte esterase, and 1165 bacteria. She was started on intravenous (IV) Rocephin. Her blood cultures remained negative. Her urine culture was contaminated. She signed herself out against medical advice and was advised to continue her double strength Bactrim tablets twice a day to finish a five-day course.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary based on the documentation provided. The patient presented with symptoms of a urinary tract infection and was diagnosed with pyelonephritis. She was hemodynamically stable. She did not have severe or persisted changes in mental status. She did not have persistent or worsening clinical findings despite observation care. She did not require intravenous (IV) antibiotics beyond what could be provided at a lower level of care. She was not documented to be pregnant. She was not significantly immunocompromised nor did she have significant uropathy or ureteral obstruction. She did not have acute kidney failure. She did not require prolonged IV hydration. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Dermatitis.
Treatment: Pharmacy/Prescription Drugs-Dupixent.
The health plan denied the requested medication-Dupixent as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with moderate to severe atopic dermatitis associated with lichenified papules and prurigo nodular is/eczematous papules, and dermatitis pustules of the scalp. The patient has tried and failed topical Triamcinolone and Crisaborole. The patient's cysts have made it difficult to comb her hair.
Coverage of Dupixent is under review for medical necessity.

The health plan denial of Dupixent coverage is recommended to be upheld, in whole.

No. The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors or more potent topical steroids (such as Fluocinonide or Betamethasone), and/or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil) that would obviate the need for further topical therapies (despite these oral medications not being required step therapy for Dupixent). Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, as per the patient's health plan policy language, [1] and consistent with current medical literature, [2-5] the requested Dupixent is not medically necessary and does not meet the health plan coverage requirements.
The patient's scalp involvement is not so great that more potent topical steroids (such as Fluocinonide or Betamethasone) would be inappropriate for use in patients even this young age. Use of the calcineurin inhibitor tacrolimus ointment (perhaps pimecrolimus, another calcineurin inhibitor but which is a cream, would be a reasonable alternative) is also appropriate to control this patient's condition and to reduce if not eliminate the need for systemic therapies. Alternative systemic therapies (Methotrexate, Cyclosporine, or Mycophenolate Mofetil) have been used in children of this young age, but with appropriate and more potent topical therapies being utilized then the need for any systemic therapy might not be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease. 
Treatment: 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services) of Level 2 Personal Care Assistance (PCA) services. 

The insurer denied coverage for 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services) of Level 2 Personal Care Assistance (PCA) services. 

The denial is upheld. 

This is a patient with Parkinson's disease. She lives in senior housing in a studio apartment on the first floor. She is requesting the (mistakenly approved by the insurer) continuation of 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services), which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive function is described as "modified independent." She is fully alert, oriented and able to make her needs known. She is able to activate a personal emergency response system (PERS). The patient requires maximal assistance for personal hygiene, dressing, and toilet transfers. She is frequently incontinent of bladder and infrequently of bowel. Extensive assistance is needed for bed mobility and walking. The patient's limited cognitive deficits and significant functional impairments support the medical necessity of PCA services 12 hours/day, 7 days/week. However, her condition and functional needs are not at a level or unpredictable as to require the requested continuous care split shift; 24 hours, 7 days/week. This physician would also agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the authorized PCA services 12 hours/day, 7 days/week. 

From a physical medicine and rehabilitation perspective, 24 hours/day, 7 days/week (2 shifts of 12 hours of aide services) of Level 2 PCA services is 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 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services) of Level 2 Personal Care Assistance (PCA) services is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a previously healthy woman who presented to the emergency department (ED) with right upper quadrant abdominal pain and symptoms related to her known biliary colic. She had previously been evaluated in the ED for these complaints. At the time of presentation, the patient was without fever and the heart rate was 66/minute. She had a tender right upper abdomen per the examination. The white blood cell (WBC) count was 10.3 K. The complete metabolic panel identified elevated transaminases and alkaline phosphatase with normal bilirubin. Ultrasound (previously performed) showed findings of gallstones. She was treated with laparoscopic cholecystectomy. 

The inpatient hospital admission was not medically necessary.  Based on the submitted clinical documentation, an inpatient level of care was not medically necessary. This patient presented to the hospital and was admitted with the diagnosis of cholelithiasis/cholecystitis. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues that mandated an inpatient designation. She remained stable and was discharged from the hospital.

Inpatient level of care was not medically necessary. A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative intravenous (IV) fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records. She was tolerating a diet and oral analgesia following the surgical procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: breast cancer
treatment: Bioelectrical Impedance Spectroscopy
The insurer denied Bioelectrical Impedance Spectroscopy. The health plan's determination is overturned. 

The patient is a female underwent mastectomy of invasive breast cancer without radiation therapy who was undergoing surveillance by her surgeon who recommended surveillance bioelectrical impedance spectroscopy (BIS) to evaluate lymphedema. The postoperative evaluation done 8 months after surgery demonstrated no clinical evidence of lymphedema.

Bioelectrical Impedance Spectroscopy is likely to be more beneficial than standard treatment as the patient had high risk factors for lymphedema. Well-established risk factors include mastectomy and removal of 5 or more lymph nodes The patient's risk of developing lymphedema was greater than 10 -15 % based on mastectomy alone and higher with the significant number (6) of lymph modes removed.
The use of BIS to identify and prevent progression of lymphedema has data to support its benefit advantage over established variable tape measurements of arm circumference in identifying and thus allow earlier intervention for patients at higher risk of developing lymphedema.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: breast cancer
treatment: Bioelectrical Impedance Spectroscopy
The insurer denied Bioelectrical Impedance Spectroscopy. The health plan's determination is overturned. 

The patient is a woman who was diagnosed with left breast cancer for which she underwent a left total mastectomy with sentinel lymph node biopsy. The surgical pathology demonstrated invasive ductal carcinoma, grade 2, measuring 5 millimeter (mm) in greatest dimension with ductal carcinoma in situ (DCIS) and microcalcifications. All margins were clear. Six sentinel lymph nodes were removed, none of which contained metastatic carcinoma. As a part of her ongoing care, Bioelectrical Impedance Spectroscopy (BIS) was initiated in order to monitor her for subclinical evidence of lymphedema. 

Bioelectrical Impedance Spectroscopy (BIS) is likely to be more beneficial than any other assessment for the identification of subclinical lymphedema. There are several reports in the peer-reviewed literature, including meta-analyses, prospective randomized trials and prospective observational studies that demonstrate the clinical utility and impact on patient management of the use of BIS to assess lymphedema, as in this case. BIS is no longer considered to be investigational for the detection of subclinical lymphedema in patients with breast cancer who are at high risk for the development of lymphedema. In fact, BIS is a simple, non-invasive and relatively inexpensive test that can significantly impact the quality of life of patients with breast cancer and at a high-risk of developing lymphedema. Further, there is published data speaking to the significant savings that result from the routine use of BIS assessment for patients with breast cancer.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: breast cancer
treatment: Bioelectrical Impedance Spectroscopy
The insurer denied Bioelectrical Impedance Spectroscopy. The health plan's determination is overturned. 

The patient is a female with left breast cancer status/post (s/p) mastectomy with sentinel node biopsy (6 lymph nodes removed).

Bioelectrical Impedance spectroscopy is likely to be more beneficial than traditional standard evaluation of lymphedema because it allows for the early detection of lymphedema even before physical signs of lymphedema start, therefore allowing for early intervention and treatment.
Lymphedema is a debilitating morbidity of mastectomy, axillary dissection and radiation therapy Lymphedema, if caught early, can decrease morbidity and allow for stabilization of edema.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's ileitis
Treatment: Stelara (260 mg [milligrams] once) - J3358 For Intravenous Injection, 1 mg
The insurer denied the Stelara (260 mg once) - J3358 For Intravenous Injection, 1 mg.
The denial is upheld.

The patient is a male with Crohn's disease. The patient has ileitis. The patient has not used any therapy. The request is for Stelara. The patient is noted to have mild symptoms of disease.

No, the requested Stelara is not medically necessary.

As the patient has milder disease, use of conventional therapeutic medications such as methotrexate, 6-MP (mercaptopurine), or azathioprine would be appropriate.

Per ACG (American College of Gastroenterology) guidelines for the management of Crohn's disease, "Thiopurines (azathioprine, 6-mercaptopurine) are effective and should be considered for use for steroid-sparing in Crohn's disease (Strong recommendation, low level of evidence).

Azathioprine and 6-mercaptourine are effective therapies and should be considered for treatment of patients with Crohn's disease for maintenance of remission (strong recommendation, moderate level of evidence)."

Therefore, given the above, the requested Stelara 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: Upheld

Diagnosis: Tachycardia
Treatment is an inpatient admission  
The insurer denied coverage for an inpatient admission
The denial is upheld

This patient presented to the hospital complaining of palpitations and was found by EMS (emergency medical services) to have a heart rate of greater than 200 bpm (beats per minute). She was treated on site with an adenosine injection and was brought to the hospital. Upon arrival, vital signs were stable BP (blood pressure) was 96/66 mmHg (millimeters of mercury) and a pulse of 109bpm.  Physical examination revealed no significant abnormality. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic ST (interval on an ECG (electrocardiogram)) or T wave (interval on an ECG) abnormalities. Serum blood testing demonstrated grossly normal thyroid function and electrolytes. She was treated with metoprolol for supraventricular tachycardia and admitted to the hospital for observation. Following consultation with a cardiac electrophysiologist she was discharged. 

The health care plan acted reasonably with sound medical judgment and in the best interest of the patient. This patient presented with supraventricular tachycardia that responded to adenosine therapy. There were no significant abnormal findings on physical examination or a subsequent ECG to warrant acute inpatient hospital admission. Treatment of supraventricular tachycardia can be performed with AV (atrioventricular) nodal blocking medications in an outpatient setting. Most patients with palpitations can be evaluated in an outpatient setting. (Reference 1-2). In conclusion, an acute inpatient admission was not medically necessary in this case.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.