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

Diagnosis: Back Pain and Body Aches
Treatment: Continued Skilled Nursing (SNF)
The insurer denied: Continued Skilled Nursing (SNF)
The denial is overturned.

The patient is an adult female with a history of general debility due to general body aches and back pain due to a tick-borne illness. She was later diagnosed with H-Influenza bacteremia and treated with intravenous ceftriaxone. Her relevant past medical history includes hyperlipidemia, Lyme disease, and low back pain with spasms. Ongoing medical issues included continuing intravenous antibiotics. Home intravenous nursing infusion service could not be started until 5 days post the last covered day. The patient was discharged from the skilled nursing facility on the day prior to initiation of home infusion. Prior to admission, the patient was independently living with her spouse in a two-level home while also independent with activities of daily living and driving. She was admitted to the skilled nursing facility for 12 days. As of 2 days prior to discharge, she was supervision to independent for most activities of daily living.

The requested health service is medically necessary.

The proposed stay in the skilled nursing facility is medically necessary because of the need for the patient to continue to have intravenous antibiotics, and the home intravenous nursing infusion service could not be started until the day after she was discharged. The patient was discharged from the skilled nursing facility on the day prior to the schedule home infusion. A discharge prior, without arrangement for continued intravenous antibiotics, would have placed the patient in jeopardy with the infection. Therefore, a stay in skilled nursing facility was medically necessary for the requested dates under review.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Hypertension; obesity.
Treatment:  Tribenzor.

The insurer denied Tribenzor.  The health plan's determination is upheld. 

The patient is a male with hypertension, hyperlipidemia, obesity, and insulin resistance. Tribenzor was prescribed. This was denied by the health plan and is the subject of this review.

A formulary exception is not indicated in this case. The patient has not failed or been intolerant to and has no contraindication to any formulary agents. There is no documentation as to why the patient could not be treated with formulary agents olmesartan, amlodipine, and hydrochlorothiazide taken separately. There is also no documentation as to why any combination of formulary angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics could not be used in combination for treatment of hypertension. In summary, the formulary drug will not be ineffective, has not been ineffective, would be as effective as the nonformulary drug, and would not have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aspiration pneumonia
Treatment: Skilled nursing facility alternate level of care
The insurer denied Skilled nursing facility alternate level of care.
The health plan's determination is overturned. 

The patient is a male who was initially hospitalized for respiratory distress with aspiration pneumonia. He was found to have tracheal narrowing requiring the placement of a tracheostomy. He was transferred to the skilled nursing facility (SNF) for further care including, tracheostomy care, and speech/swallow therapy. In addition, he is on 28 percent (%) oxygen supplementation. He is currently requiring evaluation for capping with possible decannulation and frequent suctioning. The patient lives in a group home and is unable to make his needs known.
At issue is the medical necessity of Skilled nursing facility alternate level of care.

The requested health service/treatment of Skilled nursing facility alternate level of care is medically necessary for this patient.
This patient was hospitalized for respiratory distress with aspiration pneumonia. He was found to have tracheal narrowing requiring the placement of a tracheostomy. He was transferred to the SNF for further care including, tracheostomy care, and speech/swallow therapy. In addition, he is on 28% (percent) oxygen supplementation. He is currently requiring evaluation for capping with possible decannulation and frequent suctioning. The patient lives in a group home and is unable to make his needs known. Therefore, while he has the tracheostomy in place, he requires close monitoring with skilled personnel due to his tracheostomy status. Both the tracheostomy care and therapy require skilled care and monitoring for suctioning and pulmonary hygiene, which would be unmanageable/unsafe at a lower level of care due to the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back surgery
Treatment: Inpatient hospital stay
the insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

This is a female with a history of right leg pain. The provider has recommended a lumbar discectomy that was performed. There were no complications of the procedure. The patient was discharged home the same day. 

The inpatient hospital admission was not medically necessary. A lumbar discectomy is an outpatient, ambulatory procedure and does not require an inpatient admission. This particular patient underwent a lumbar discectomy and was discharged home on the same day. The patient could have been safely cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Dental Issues
Dental/orthodontic treatment

Diagnosis: Class II malocclusion 
Treatment: Braces
The insurer denied braces.
The health plan's determination is overturned. 

The patient in question is a young female. She has a Class II malocclusion with severely crowded arches. Tooth 10 is in anterior crossbite. She is treatment planned for braces to correct the crowding and crossbite.

Braces are medically necessary. Tooth 10 is in crossbite with tooth 22. Additionally, tooth 22 is being pushed labially in the dental arch and is developing recession. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. These problems are much more time consuming and difficult to correct than the patient's current orthodontic problem.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

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

The patient is a male admitted to the hospital. The patient presented with nausea vomiting and abdominal pain. The pain is primarily in the right upper quadrant (RUQ). He has a history of pancreatitis and believed he was experiencing a flare. There was no history of (H/O) alcohol, and the pancreatitis was thought to be from hypertriglyceridemia. On admission, vital signs were stable, he was afebrile. He appeared generally well, in no acute distress. Abdomen was with right upper quadrant (RUQ) tenderness without guarding or rebound. No epigastric pain and no description of pain radiating to the back was noted. The patient was started on LR (lactated ringers) along with intravenous (IV) acetaminophen. 

The inpatient level of care was not medically necessary. The patient perhaps had pancreatitis, although by Atlanta criteria he did not necessarily meet that definition [the pain complaint does not sound classic for pancreatitis and there is no computed tomography (CT) evidence of pancreatitis to secure the diagnosis]. Regardless, the patient did not appear acutely ill and there were no life-threatening complications present such as hemorrhage or infection which can complicate severe pancreatitis. In addition, he did not have systemic complications of pancreatitis such as adult respiratory distress syndrome (ARDS), acute kidney injury, or severe electrolyte abnormalities. If the patient had stayed, management would have largely been supportive with intravenous (IV) lactated Ringers and anti-emetics as needed (PRN). This could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who was hospitalized secondary to the presence of left lower extremity (LLE) erythema, pain, and swelling. Additional medical history includes heart failure with reduced ejection fraction (HFrEF), hypertension (HTN), hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease (COPD) (requiring home oxygen therapy), venous stasis, and recent hospitalization for left lower extremity (LLE) cellulitis. He had not received oral antibiotic therapy for approximately 9 days prior to this hospitalization. Initial laboratory data demonstrated mildly increased inflammatory markers. Initial imaging studies including an x-ray, lower extremity ultrasound, and computed tomography (CT) scan of the left lower extremity (LLE) did not reveal an abscess, osteomyelitis, or thrombus. Cultures (blood and wound) were obtained and were unrevealing. Initial therapy included intravenous (IV) vancomycin and piperacillin/tazobacatam. Clinical improvement of LLE erythema was not noted and the attending physician felt the findings may be most consistent with venous stasis. He was discharged home with by mouth (PO) Augmentin therapy. At issue is the medical necessity of an inpatient stay.

Based on the information provided, the requested health service/treatment of inpatient admission was not medically necessary for this patient.
This patient was afebrile, hemodynamically stable, and tolerating oral intake. The patient was not taking antibiotic therapy in the outpatient setting. While it is clear this patient needed diagnostic assessment and medical treatment, it was not medically necessary for this assessment and care to provided in the acute inpatient care setting. The medical care provided could have safely and effectively been delivered at a lower level of care. The requested acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Urinary tract infection.
Treatment:  Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is overturned.

The patient is a male with a past medical history of end stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), hypertension, and urinary tract infection (UTI), who presented to the emergency department (ED) for suprapubic pain during dialysis. The pain radiated to his upper chest. 

The patient was admitted for suprapubic and chest pain. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with nonspecific T wave inversions. The patient was treated with intravenous (IV) antibiotics for acute cystitis. The patient was noted to have a prior urinary tract infection (UTI) with Klebsiella. It was noted that the patient has a recurrent urinary tract infection (UTI) almost every 2 weeks. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital admission was medically necessary. The patient was admitted for a urinary tract infection (UTI) in the setting of ESRD and recurrent UTI.

Complicated UTIs are associated with patient-level factors that compromise urodynamics or host defenses, such as indwelling or intermittent urinary catheterization. A prior history of UTI is risk factor for complicated and recurrent UTI, multi-drug resistance and secondary bloodstream infections. Multidrug-resistant organisms (MDRO) are predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. Patients with recurrent UTI requiring frequent antibiotics are at increased risk for MDRO and are likely to be hospitalized for intravenous (IV) antibiotics. It is well described in the literature that multi-drug resistant (MDR) bacteria are more prevalent the patients with prior history if UTI and antibiotics resistance. It was therefore necessary to wait for a urine final urine culture and complete a minimum of five days of IV antibiotics. Overall, UTIs in ESRD patients have the potential for serious complications and mortality and therefore must be treated with antibiotics tailored to the organism to avoid treatment failure and complications.

The patient's stay was medically necessary at the inpatient level of care, due to high risk for complications and potential for resistant organisms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Status post bilateral prophylactic mastectomy and implant reconstruction.
Treatment:  Magnetic resonance imaging, breast, without contrast material; bilateral, codes 77047.

The insurer denied coverage for magnetic resonance imaging, breast, without contrast material; bilateral, codes 77047.  The denial is overturned.

This is an adult female who is a BRCA2 gene carrier and had double mastectomies in 2011. Recent Ultrasound was inconclusive, thus her physician recommended Magnetic Resonance Imaging (MRI) for the evaluation of silicone gel implants, as rupture cannot be detected on physical examination. 

According to the referenced literature, Breast Magnetic Resonance Imaging (MRI) used as a screening test in women at high risk of breast cancer has been shown to be significantly superior to mammography and ultrasound. Further, Annual breast MRI is recommended for high-risk patients, most particularly those who have a higher than 20 percent lifetime risk of developing breast cancer. In addition, Magnetic Resonance Imaging (MRI) is the most accurate test to assess the integrity of implants. 

According to the Food and Drug Administration (FDA), the updated rupture screening recommendations follow the consensus recommendation of the Panel to remove the current FDA MRI screening recommendations, and to adopt screening recommendations that begin between years 5 and 6 post-surgery and occur every 2-3 years after that. Additionally, the FDA is also recommending ultrasound, as an acceptable alternative for screening asymptomatic patients pursuant to the Panel's recommendation. These additional labeling recommendations were discussed at the March 2019 Panel Meeting.

In this case, an adult female with a diagnosis of acquired absence of bilateral breasts and nipples has undergone bilateral nipple sparing mastectomies and implant-based reconstruction. On examination, she has excellent volume and shape symmetry is noted. Implants remained soft and mobile. She does have a 2 cm (centimeter) diameter pigmented lesion in the medial aspect of the left breast, which is consistent with a seborrheic keratosis. The patient is BRCA2 positive, bilateral breast sonography was performed, and there were no masses or lymphadenopathy noted. Inconclusive ultrasound warrants an MRI, which is considered the most accurate test. 

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 magnetic resonance imaging, breast, without contrast material; bilateral, codes 77047 services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered Mental Status
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a past medical history notable for hemorrhagic cerebrovascular accident (CVA), seizure disorder, hypertension, and hyperlipidemia, who was brought to the emergency department by Emergency Medical Services (EMS) after being discovered in the street, exhibiting confusion and a disheveled appearance. The patient reported weakness and hunger.
According to the ambulance report, a concerned pedestrian had alerted EMS about the patient, who had been wandering aimlessly in the neighborhood for two days. At the time of the call, the patient was attempting to break into a car, mistakenly believing it was his own. He was ambulatory but severely confused and unable to recall his date of birth.
A chest x-ray and computed tomography (CT) scan of the head revealed no acute cardiopulmonary abnormalities. The patient received intravenous fluids in the ED and was subsequently admitted to the medicine service for metabolic encephalopathy.
During the hospitalization the patient was diagnosed with an acute kidney injury, resulting from dehydration and rhabdomyolysis, possibly triggered by a seizure. The patient continued to receive intravenous fluids during his stay and was evaluated by the neurology service, leading to treatment with Keppra. Although there was a gradual improvement in his mental status, he did not return to his baseline. The decision was made to discharge the patient to a long-term care facility. This proved challenging, as several facilities declined admission. Eventually, a facility accepted the patient, and after obtaining prior authorization, he was discharged from the hospital. At issue is the medical necessity of an inpatient stay.

The patient's admission to the acute inpatient level of care was medically necessary/justified based on a comprehensive assessment of his clinical condition. Initially presenting with altered mental status, the patient remained confused and disoriented for an extended period beyond what is considered reasonable for a lower level of care. Given this persistent mental impairment, it was deemed unsafe to discharge him from the hospital, particularly as his mental status never returned to his baseline.
The patient's medical history revealed a pattern of noncompliance with medications, which likely contributed to a possible seizure, subsequently triggering encephalopathy and leading to dehydration and acute kidney failure. His medical condition necessitated continued treatment for acute kidney injury and dehydration, requiring close monitoring of kidney function and electrolyte levels.
Efforts were made to arrange discharge to a long-term care facility, but multiple refusals to accept the patient were encountered, prolonging his hospitalization well beyond the reasonable timeframe for a lower level of care.
Considering the complex and protracted nature of his medical issues, admission at the acute inpatient level of care was essential for his ongoing evaluation and treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrogastric Fistula

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission

The denial is upheld

The health plan acted reasonably and in the best interest of the patient. Per clinical documentation, the patient has a history of a lap band removal and gastric bypass and now has a gastrogastric fistula. This caused failure to lose weight and increased malabsorption. The patient was admitted for an elective procedure. The patient underwent endoscopic revision of the gastric pouch and closure of the gastrogastric fistula. During the procedure, an Apollo OverStitch device was used to close the fistula defect. There were no noted complications resulting from the procedure. The patient was discharged the following day, within 24 hours. Gastric and esophageal stent placements have been shown to decrease inpatient stay [1]. Per Milliman Care Guidelines (MCG) criteria, endoscopic procedures are considered ambulatory [2]. There were no additional criteria noted that would warrant an inpatient stay for this patient. Therefore, the inpatient admission was not medically necessary for this 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

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

The patient is a male with a known history of seizure disorder and non-compliance with his medications. He was brought to the hospital by his family after having a seizure. He had one minute of convulsions. He did not recall the events. He denied any neurologic symptoms. The patient was seen by the neurologist in the emergency department. The neurologist diagnosed multiple seizures in the setting of underlying epilepsy. Seizures were occurring in the setting of medication non-compliance. The neurologist recommended restarting his anti-seizure medications. If he did not return to baseline cognition, they would proceed with electroencephalogram (EEG) and magnetic resonance imaging (MRI) of the brain. The patient had another seizure in the emergency department. He was given intravenous (IV) Ativan. A computed tomography (CT) of the head was inconclusive. The patient was admitted to the hospital for further care.

The inpatient hospital admission was not medically necessary for this patient.
The patient was admitted for seizures in the setting of medication non-compliance. He required observation due to recurrent seizure in the emergency department. He was restarted on his home medications. He ultimately did not require any additional treatment for his seizures other than restarting his home medications. He did develop swelling of his elbow consistent with infection. He was started on antibiotics. He did not fail to respond to treatment or show any hemodynamic instability. There was no indication for escalation of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscess
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who presented to the emergency department with complaints of pain and bleeding from an anal fistula. He reports having a fever at home as well. The patient states he had a similar episode several years ago that responded to drainage and antibiotic therapy. He was noted to have a temperature of 99 degrees. He was hemodynamically stable with a heart rate of 114. Physical exam confirmed tenderness over the left perianal region. His white blood cell (WBC) count was elevated at 15,200 and a computerized tomography of the abdomen and pelvis (CTAP) confirmed the presence of a horseshoe abscess. The patient was started on antibiotics and admitted to acute inpatient status. He was taken to surgery later that same day where he underwent incision and drainage of a perirectal horseshoe abscess and placement of a seton. He was discharged home in stable condition on postoperative day #1 to be followed in clinic. The health plan denied the admission as not medically necessary. The provider has appealed that decision.

The requested health service was not medically necessary.

The patient presented to the emergency department with complaints of perianal pain and drainage secondary to a fistula-in-ano with associated abscess formation. In the emergency department, the patient was noted to be hemodynamically stable. He received intravenous fluids, antibiotics, and analgesics. He was taken to surgery that same day for a drainage procedure and subsequently discharged from the hospital the following day. The medical record indicates that the patient was noted to be ambulatory, tolerating diet, voiding, and pain free following surgery. He was discharged to home approximately 24 hours following his presentation in the emergency department. The services rendered do not rise to the level supporting acute inpatient care and could have been provided on an alternative level of care. Therefore, the requested health service is not medically necessary.