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

Diagnosis: Cardiac/Circulatory Problems/Chest Pain
Treatment: Full Hospital Admission
The health plan denied the requested full hospital admission as not medically necessary. The health plan's determination is upheld.

The patient is a woman with a history of diabetes and hypertension. She presented to the emergency room with a two-day history of chest pain and shortness of breath. The vital signs were normal. She was in no acute distress and well-appearing. The physical exam was negative except for a body mass index (BMI) of 44. Labs were notable for a glucose of 260 and a minimally elevated creatine kinase (CK). The chest x-ray showed no acute pulmonary disease. There were no electrocardiogram (EKG) tracings in the materials provided. In one note it was mentioned that there were inferolateral T-wave inversions with premature atrial contractions (PAC). In another note it was written that the T-wave inversions were unchanged from a previous tracing four years previously. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with Aspirin, insulin, and her home oral medications. An echocardiogram was performed which reportedly showed normal systolic function and mild concentric left ventricular hypertrophy (LVH). A stress test was reportedly positive for ischemia and exercise induced ventricular and atrial contractions. A cardiac catheterization was apparently performed , revealing normal coronary arteries. Like the EKG, there were no specific reports in the information provided documenting the echocardiogram and cardiac catheterization. The hospital course was clinically uneventful, and the patient was discharged.
At issue is the medical necessity for the requested health service/treatment of full hospital admission.

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

No, the requested health service/treatment of full inpatient admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested full acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The EKG changes that apparently prompted the patient's primary care physician to send her to the emergency room (ER) were not new. There was no hemodynamic instability, respiratory distress, severe pain, mental status changes, or severe metabolic disarray. The services provided - oral medications, insulin, echocardiogram, cardiac catheterization- 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 an alternate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fall Risk.
Treatment:  Personal care worker (PCW) service 7 days per week, 12 hours per day, 84 hours per week.

The insurer denied Personal care worker (PCW) service 7 days per week, 12 hours per day, 84 hours per week.  The determination is overturned.

This is a male patient with a medical history notable for fall risk and recent hospitalization. The patient was approved for 7 hours per day, 7 days per week (49 hours per week) of personal care worker services. The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was partially denied by the health plan; they did approve an increase to 8 hours per day, 7 days per week (56 hours per week).

The patient's daughter provided a letter of support for this appeal. The letter states that her father has had a significant decline in function since a hospitalization for coronavirus disease (COVID) pneumonia. The patient is now bed bound and cannot perform any tasks independently. He must follow a puree diet. He requires help for transfers, walking, and toileting. Physical therapy and home health notes were provided as part of this review. These notes were reviewed in detail.

There was no Uniform Assessment System (UAS) provided as part of this appeal. However, a letter of advocacy states that a Uniform Assessment System (UAS) was done. The final adverse determination notice also references this assessment, which states that the patient's personal care needs include grooming, dressing, bathing, locomotion, transfers, toileting, meal preparation, and feeding. There is also a reference to a task tool which recommended 5.3 hours per day to address the patient's personal care needs. At issue is the medical necessity of personal care worker (PCW) service 7 days per week, 12 hours per day, 84 hours per week.

The requested health service of personal care worker (PCW) service 7 days per week, 12 hours per day, 84 hours per week is medically necessary for this patient.

According to the records, the patient relies on others for all transfers and activities of daily living. He relies on others for toileting, transfers, locomotion, meal preparation of pureed foods, and eating. These personal care needs are expected to be continuous and unscheduled in nature. In cases of unscheduled personal care needs, a task tool cannot be relied on to reflect the true needs of the patient accurately.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-Hodgkin Lymphoma
Treatment: Inpatient Hospital
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female who was recently discharged from another medical center and was readmitted to the current medical center on. The patient noted subacute fatigue and weight loss. The patient was hemodynamically stable, afebrile and had cervical adenopathy upon examination. The patient's laboratory studies were remarkable for anemia and thrombocytopenia.
The patient underwent a positron emission tomography (PET)/computed tomography (CT) and placement of a Hickman catheter. She received analgesics for pain management. The patient underwent a bone marrow examination. Ultimately, the patient was found to have metastatic rhabdomyosarcoma. She was started on Vincristine, Dactinomycin, and Cyclophosphamide. 

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. This patient was admitted for inpatient care with acute complaints. She had subacute complaints of pain, weight loss, and adenopathy. Imaging was concerning for cancer. The patient was hemodynamically stable. Her laboratory studies were not critical. In the course of her evaluation, she underwent diagnostic studies that are typically performed at a lower level of care - including the ambulatory setting (PET/CT, bone marrow biopsy, line placement, etc.). The patient subsequently received her first cycle of a chemotherapy regimen that does not require inpatient care for administration. She was subsequently discharged. Her nursing care was primarily supportive in nature. Neither the peer-reviewed literature, national guidelines, nor the authors of UpToDate recommend inpatient care in this clinical scenario. For these reasons, medical necessity for this hospitalization cannot be established.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystoscopy complication

Treatment: Admission to inpatient level of care

The insurer denied coverage for admission to inpatient level of care

The denial is upheld

According to the medical records, the patient is an adult male with a history of hypertension, obstructive sleep apnea, and diabetes mellitus. The patient presented to the Emergency Department (ED) with abdominal pain, fever, and difficulty urinating after a cystoscopy. The patient had a Computed tomography (CT) of the abdomen/pelvis and received antibiotics. The patient was admitted to the medical service and had a Urology consult. When stable the patient was discharged to follow-up with his primary care physician and Urologist. 

The patient presented to ED with abdominal pain, fever of 101.7 degrees Fahrenheit (F), resolving to 99.3 F and difficulty urinating after a cystoscopy. Urology consult recommended CT of the abdomen/pelvis which was unremarkable showing transurethral resection of prostate (TURP) defect and ultrasound (US) of the scrotum which showed varicocele with no torsion. Laboratory results were notable for urinalysis with Leukocytes of 500, White Blood Cells (WBC) 15.7. 

The patient was admitted and was able to urinate without straight catheterization, Intravenous (IV) antibiotics were switched to oral, and the patient was discharged to follow-up with the primary care physician and Urologist managing the care. 

"Complications of cystoscopy are generally minor and may include urinary tract infection, hematuria, dysuria, and injury to the bladder or urethra. The development of an iatrogenic urethral stricture is a known possible complication of instrumentation." (Engelsgjerd, JS. et al. 2022)

"Cystoscopy is used to diagnose, monitor and treat conditions affecting the bladder and urethra. Your doctor might recommend cystoscopy to investigate causes of signs and symptoms. Those signs and symptoms can include blood in the urine, incontinence, overactive bladder and painful urination. Cystoscopy can also help determine the cause of frequent urinary tract infections. However, cystoscopy generally isn't done while you have an active urinary tract infection." (Cystoscopy Mayo Clinic 2022)                                                         

Admission to inpatient status was not necessary and services could have safely been administered at the outpatient observation level. Therefore, the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

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 admission to inpatient level of care is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System/Asthma
Pharmacy/Prescription Drugs/Dupixent
The health plan denied the requested prescription medication, Dupixent, as not medically necessary. The health plan's determination is overturned.

The patient is a female seeking approval for Dupixent. Her provider wrote an appeal letter noting severe persistent asthma requiring Prednisone multiple time during her lifetime. She is on bronchodilators and inhalers. The health plan denied the request for Dupixent, as there were no pulmonary function tests (PFT) available. The patient is on Breztri. She has been on Breo and Symbicort in the past. She is also on Singulair. The patient did take Prednisone twice in the past year for exacerbations. PFT results noted forced expiratory volume (FEV1) of 52% predicted, with an improvement in forced vital capacity (FVC) at 9%.
At issue is the medical necessity for the requested health service/treatment of Dupixent.

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

Dupixent is medically necessary for this patient.
The patient is over 6 years old. The patient did have significantly abnormal PFTs with an FEV1 less than 80% with borderline reversibility with a 9% improvement in FVC. The patient does have oral corticosteroid dependent asthma and has been trialed for 3 months on high dose inhaled corticosteroids, in addition to Prednisone on multiple occasions. She has had 2 two asthma exacerbations in the past year. Based on these points, Dupixent is medically necessary. According to current literature, the patient would benefit from this medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical stenosis
Treatment: Spinal surgery (codes 22853, 22551, 22554, 22846, 22552)
The insurer denied coverage for spinal surgery (codes 22853, 22551, 22554, 22846, 22552)
The denial is upheld

The indications for surgery include definition of the specific pain generator, failure to improve with conservative treatment and likelihood the operation will provide benefit. 

The facts are the patient has never improved despite lumbar procedures, hand operations, chronic opioid use and several pain management procedures to his neck. There is lack of consistency in the medical record for "stenosis or nerve compression in the cervical spine". His subjective complaints do not correlate. He has been reported to have ongoings symptoms of numbness to the median nerve distribution. His physical examination demonstrated loss on one occasion. The findings were global and nonspecific. He was reported to have positive (+) Tinel and Phalen tests. His electromyogram (EMG) cannot be discounted showing peripheral nerve compression. The reported cervical (C) 6-7 radiculopathy did not correlate with his "bilateral symptom" presentation. It is important to recognize the 90% reported relief after radiofrequency ablation (RFA). This signifies facet disease. The imaging study did not vary from a previous report. Simply stated there was multilevel degenerative disease but no evidence of specific nerve root compression. There was no evidence of cord compression. 

The proposed diagnosis of cervical stenosis and neurogenic claudication is not supported. The pain patterns were inconsistent with several other conditions which more than likely could be causative. (Diabetes, peripheral nerve compression, facet disease). It is extremity unlikely that the planned procedure will provide benefit. Also noted are documented post laminectomy syndrome and chronic narcotic use. There is no indication for the requested reconstructive cervical spine procedure. 

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 spinal surgery (codes 22853, 22551, 22554, 22846, 22552) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sore Throat and Cough
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld

The patient is an adult female. She presented to the ER (emergency room) for evaluation of sore throat, cough, and hemoptysis. During the ER (emergency room) evaluation, the patient was found to have pneumonia. The patient was treated with IV (intravenous) antibiotics. The patient was admitted to the hospital for further work up and treatment. The inpatient admission was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient admission was not medically necessary.

The patient was diagnosed with pneumonia that failed outpatient treatment. At the time of admission, the patient was hemodynamically stable. The patient was not on any invasive drips. The patient did not require supplemental oxygen. The acute inpatient level of care is not medically necessary. The patient could have been safely and effectively treated at a lower level of care. Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endometrial cancer
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

The patient is an adult with a history of endometrial cancer, who underwent a robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral sentinel lymph node injection and bilateral pelvic lymph node dissection. There were no complications, though double vision, unsteady gait and decreasing blood pressure to 90s/40s was noted postoperatively. The patient was admitted for overnight monitoring. There were no acute events overnight and the patient was discharged the next day.

Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines, Inpatient and Surgical Care 26th Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:

Surgical complications (bladder ureter or bowel injury or hemorrhage)
Conversion to abdominal hysterectomy
Complex surgery (staging of endometrial cancer)
Wound complications
Comorbidities.

This patient, because of her diagnosis of endometrial cancer, had complex surgery.  Her surgery involved pelvic lymph node dissection. According to the scientific literature, the average length of stay for such patients is 48 hours in the hospital. 

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

Diagnosis: Endometrial cancer

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

The patient is an adult with a history of endometrial cancer, who underwent a robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral sentinel lymph node injection and bilateral pelvic lymph node dissection. There were no complications, though double vision, unsteady gait and decreasing blood pressure to 90s/40s was noted postoperatively. The patient was admitted for overnight monitoring. There were no acute events overnight and the patient was discharged the next day.

Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines, Inpatient and Surgical Care 26  Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:

Surgical complications (bladder ureter or bowel injury or hemorrhage)
Conversion to abdominal hysterectomy
Complex surgery (staging of endometrial cancer)
Wound complications
Comorbidities.

This patient, because of her diagnosis of endometrial cancer, had complex surgery.  Her surgery involved pelvic lymph node dissection. According to the scientific literature, the average length of stay for such patients is 48 hours in the hospital. 

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

Diagnosis: Kidney stone.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.
 

This patient had past medical history of hypertension, hypothyroid, morbid obesity. Patient presented to emergency department with abdominal pain, bilateral flank pain. Patient had recently undergone lithotripsy of a renal stone. Patient was evaluated in emergency room, admitted taken to operating room by urology for cystoscopy, right Ureteroscopy with laser lithotripsy. Stent placement. Surgery was uncomplicated and patient recovered uneventfully, she was stable for discharge home with outpatient urology follow up. 

Per Milliman Care Guidelines (MCG) Health (26th) renal colic and kidney stones RRG, patient fails to meet clinical indications for admission to inpatient care. Also, per MCG Health (26th) urologic surgery or procedure GRG, patient is noted to have met the GRG discharge parameter within 24 hours post procedure. As per the guideline, this procedure is performed in the ambulatory surgery setting. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

A full hospital admission was not considered medically necessary for this patient. Patient had no urinary tract infection, hemodynamic instability, acute renal failure or bilateral obstruction.
 
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 a full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Maxillary Infection
Treatment: inpatient admission
The insurer denied the inpatient admission. The health plan's determination is overturned.

The patient is a male who was referred to the Emergency Department (ED) by the ear, nose, and throat (ENT) service. At the time, the patient had an infection in the maxillary area (along with palatal dehiscence) status post right maxillectomy, right inferior orbital wall reconstruction, right fibula free flap with dental implants, and right split thickness skin graft. 

The inpatient admission was medically necessary. The patient had a complicated infection that could not be cared for at a lower level of care. The patient had a significant surgery of the head and neck area with a severe complication that resulted in severe morbidity. The patient had pus coming from the nasal area. The white blood cell (WBC) count was elevated suggesting a severe infection. The tissue coverage of the defect in the mouth/sinus was failing and required emergency surgical treatment. An inpatient admission was indicated.
Appeal type: Medical necessity
Decision: Overturned

Ear/Nose/Throat
Inpatient hospital

Diagnosis: Maxillary Infection
Treatment: inpatient admission
The insurer denied the inpatient admission. The health plan's determination is overturned.

The patient is a male who was referred to the Emergency Department (ED) by the ear, nose, and throat (ENT) service. At the time, the patient had an infection in the maxillary area (along with palatal dehiscence) status post right maxillectomy, right inferior orbital wall reconstruction, right fibula free flap with dental implants, and right split thickness skin graft. 

The inpatient admission was medically necessary. The patient had a complicated infection that could not be cared for at a lower level of care. The patient had a significant surgery of the head and neck area with a severe complication that resulted in severe morbidity. The patient had pus coming from the nasal area. The white blood cell (WBC) count was elevated suggesting a severe infection. The tissue coverage of the defect in the mouth/sinus was failing and required emergency surgical treatment. An inpatient admission was indicated.