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

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

This is a female patient who was admitted through the emergency room (ER) with pyelonephritis. Her vital signs were temperature 96.5 degrees Fahrenheit, pulse 77, blood pressure (BP) 105 over 71 (105/71) and respiratory rate 18. A repeat BP was 109/57. Computed tomography (CT) imaging demonstrated mild left hydronephrosis and an edematous kidney. The urinalysis had white blood cells (WBCs) and nitrites. The WBC count was 6800. The creatinine was 0.97. Intravenous (IV) antibiotics, intravenous fluids (IVF) and IV nausea medication were started. She had multiple drug allergies.
She was seen by infectious disease (ID) and urology. Intravenous fluids (IVF) and intravenous (IV) meropenem were administered. She was discharged home. She was afebrile and hemodynamically stable throughout the hospital stay. At issue is the medical necessity of an inpatient admission.

A full hospital admission was not medically necessary. She was afebrile and hemodynamically stable throughout the hospital stay. ability to maintain oral hydration) despite observation care.
An acute inpatient level of care was not medically necessary. Care could have been provided at a lower level of care. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. She did not have a documented kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, severe vomiting. Pain control, IV antibiotics and IVF in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who was admitted for worsening anemia. She was treated with a blood transfusion and the blood count responded well. She was noted to have hyponatremia which improved with intravenous (IV) fluid. A computed tomography (CT) of the chest was negative for infection or pulmonary embolism. An electrocardiogram was negative for acute ischemia or arrhythmia. A CT of the abdomen and pelvis was negative for acute intra-abdominal process.

The inpatient hospital admission was not medically necessary.
The patient was admitted for worsening anemia, she was hemodynamically stable, and had no signs of active bleeding. She was also noted to have hyponatremia which was stabilized in 48 hours.
The ACG (American College of Gastroenterology) Clinical Guidelines suggest that patients identified as having a very low risk for requiring transfusion or intervention (Glasgow-Blatchford score (GBS) of 0 or 1) may be safely discharged from the emergency department with outpatient scheduling of endoscopy. (1)
Considering the outcome of need for hospital-based intervention or death, an evidence-based specialty society analysis found that a GBS of 0 to 1 had at least a 99 percent (%) sensitivity with a lower bound of the 95% confidence interval of 98%, resulting in what they conclude was an acceptably low false-negative rate. (2)
An analysis of a database including 199,008 hospitalized patients discharged with a principal diagnosis of nonvariceal upper gastrointestinal (GI) bleeding found, for patients who underwent endoscopy within 24 hours, a median length of stay of 2.5 days. In the same study, analysis of 3251 patients discharged with a principal diagnosis of variceal upper GI bleeding found, among patients who received endoscopy within 24 hours, that 25% of patients had a length of stay of 2 days or less. (3)
An analysis of 12,501 adults (mean age 58.5 years) admitted for upper GI bleed who were not receiving home oral anticoagulation reported a 2.6-day mean length of stay.(26) (EG 2) Analysis of national hospital discharge data shows 32% of hospitalized adult patients with upper GI bleeding as the principal diagnosis discharged in 2 days or less. (4)
When taking into account the patient's exam, imaging, and lab findings, the inpatient level of care was not medically necessary. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Sepsis and Fever.
Treatment:  Inpatient stay.

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

This is a case of a male admitted for a diagnosis of sepsis. The patient presented with a chief complaint of a fever. He had a history of Hodgkin's lymphoma and had treatment with Rituxan four days prior. He was found to have elevated troponin and fever. He had symptoms of chills, body aches, headache and temperature of 102.8F (degrees Fahrenheit). Physical exam showed no acute distress or altered mental status. Blood pressure was 120/69, pulse 103, respiratory rate 16 and O2 saturation 94% (percent). Creatinine was 1.14 with sodium 134. White blood cell count was 2.4. A computed tomography (CT) of the head was unremarkable. Chest x-ray was unremarkable. Urinalysis was unremarkable. 

The inpatient hospital admission was medically necessary. 
The patient in this case was admitted for sepsis and had an elevated temperature of 102.8F. He was immunocompromised with active treatment for Hodgkin's lymphoma with Rituxan. He had an elevated troponin, and leukopenia of 2.9. He appropriately had a thorough investigation including parasite evaluation, tickborne illness and widespread cultures. Given his immunocompromised state, he would require culture investigation results which would take longer than what would typically be done at a lower level of care. He would have needed accurate treatment pending these results.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polyarteritis with lung involvement [Churg-Strauss]
Treatment: Nucala 100 mg (milligrams)/mL (milliliter) Auto Injectors
The insurer denied Nucala 100 mg (milligrams)/mL (milliliter) Auto Injectors.
The denial is overturned.

This is an elderly male patient with asthma and Churg-Strauss disease (eosinophilic granulomatosis with polyangiitis [EGPA]) who is being treated with prednisone and Nucala. The patient has been on Nucala for eosinophilic granulomatosis with polyangiitis (EGPA) and asthma with good clinical response. The patient has been on Nucala for 8 years. The use of Nucala for eosinophilic granulomatosis with polyangiitis (EGPA) was denied due to lack of medical necessity. This denial is being appealed.

The requested health service is medically necessary.

This patient has eosinophilic granulomatosis with polyangiitis and has been successfully treated with prednisone 5 milligrams (MG) as well as Nucala (mepolizumab) for 8 years. The continuation of Nucala was denied since there was lack of a Birmingham vasculitis activity score and the prednisone dose was above 4 milligrams. However, the patient has been on Nucala with good clinical response. Not continuing Nucala at this point will lead to worsening of symptom control and quality of life as well as frequent doctor visits. Mepolizumab has been shown to be a safe and effective add-on treatment for the management of eosinophilic granulomatosis with polyangiitis. The continuation of Nucala is considered standard of clinical practice and it is not for the convenience of the patient or physician. It is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Elevated Blood Sugar Level and Stomach Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female who presented to the emergency room with nausea, vomiting, abdominal pain, and elevated blood sugars. She has a previous history of type 2 diabetes and was treated with insulin. The patient was found to have elevated serum glucose and serum beta-hydroxybutyrate, elevated white blood cells, and elevated urine ketones and glucose. She was admitted to the hospital and treated with intravenous fluids and intravenous insulin and then later transitioned to subcutaneous insulin. Abdominal pain, nausea, and vomiting resolved. 
The hospital stay coverage was denied by the patient's health plan due to being considered not medically necessary. Coverage of medical services was denied due to per initial review of records the patient could have been treated at a lower level of care. The appeal was requested, and records were provided.

The requested health service was medically necessary.

The patient needed intravenous hydration and intravenous insulin treatment requiring inpatient treatment that was not possible to provide at a different level of care. The patient had hyperglycemia, dehydration, and inability to maintain oral hydration due to vomiting and abdominal pain. She also had elevated ketones in her urine and blood. The patient needed to receive intravenous hydration and insulin treatment and required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rash on Cheeks (Eczematous Rash)
Treatment: Emergency Room Admission
The insurer denied: Emergency Room Admission
The denial is overturned.

This school age female patient was admitted for facial cellulitis that had failed outpatient antibiotics (two separate antibiotics) and required intravenous vancomycin for clearance. The health plan denied coverage of the hospital admission as the patient could have been seen at urgent care.

The requested health service was medically necessary.

This patient had failed two separate antibiotics as an outpatient. The patient failed outpatient therapy and required intravenous antibiotics. Antibiotics must be administered in a hospital setting with monitoring to ensure tolerance of the medication, and response of the infection. Generally, infections that have failed sufficient outpatient antibiotics require care in hospital. Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic central serous retinopathy (CSCR) and secondary choroidal neovascularization (CNV)
Treatment: Medical injectable services
The insurer denied Medical injectable services.
The determination is overturned.

The patient is a male with a long history of chronic central serous retinopathy (CSCR) and secondary choroidal neovascularization (CNV). In addition, he carries a diagnosis of age-related macular degeneration (ARMD) with CNV. He was initially treated with photodynamic therapy and failed that treatment. Control of the subretinal fluid (SRF) from the CNV has subsequently been controlled with anti-vascular endothelial growth factor (anti vascular endothelial growth factor (VEGF)) therapy alternating between Avastin (bevacizumab) and Eylea (aflibercept). His health plan has covered many of the injections of these medications, however, there is still an outstanding injection that has been deemed medically unnecessary. The health plan covers CNV in cases of diabetes, branch and central retinal vein occlusions and ARMD.  At issue is the medical necessity of medical injectable services.
The requested health service/treatment of medical injectable services is medically necessary for this patient. This patient does carry of diagnosis of ARMD per the records. In addition, he has CSCR.
CSR (Central serous retinopathy) is the fourth most common retinopathy after age-related macular degeneration, diabetic retinopathy and branched retinal vein occlusion, and typically causes central vision loss or distortion in patients. CSR is marked by one or more focal active leakage sites associated with decompensated retinal pigment epithelium (RPE) and detachment of the neurosensory retina and/or the RPE. Photodynamic therapy (PDT) has demonstrated positive results in decreasing vascular hyperpermeability and improving chronic CSR. However, as there is concern regarding safety profile with increasing limitations regarding access to new and existing machines, the reliance on PDT is often a challenge. Anti-vascular endothelial growth factor (VEGF) therapies for CSCR were initially described by Torres-Soriano et al, numerous prospective and retrospective interventional case series, comparative analyses and chart reviews have reported the outcomes of chronic CSR after anti-VEGF treatment.
The patient has a diagnosis of ARMD in his included medical records. The patient met the criteria for anti VEGF therapy outlined in a recent meta-analysis looking at these therapies for CSCR. The patient has a diagnosis of ARMD in his included medical records, for which anti VEGF therapy is considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper and lower extremity weakness
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient, with a history of gastroesophageal reflux disease (GERD), Barrett's esophagus, patent foramen ovale (PFO) and scoliosis, presented to the hospital after having acute head, neck, upper back pain, the patient felt weakness and numbness on the right side of the face and upper and lower extremities. Emergency Medical Services (EMS) reported loss of consciousness (LOC) and posturing, no tongue biting or incontinence. The patient was alert and oriented to person, place and time, with mild stuttering, National Institutes of Health Stroke Scale (NIHSS) 2, there was a mild decreased sensation on the right half of the face, right upper limb, right lower limb in comparison to the left side. During the evaluation, the patient reported improvement in her stuttering and neurological symptoms. 

The patient underwent Neurology and Cardiology evaluation including computed tomography (CT) head, Computed tomography angiogram (CTA) head and neck, magnetic resonance imaging (MRI) head, MRI Cervical and Thoracic Spine, electroencephalogram (EEG) and transthoracic echocardiogram (TTE) and transesophageal echocardiography (TEE), all of which were normal. Initial evaluation indicates the patient's total National Institutes of Health Stroke Scale (NIHSS) score was 1 and the patient is not a Tissue Plasminogen Activator (TPA) candidate due to no stroke.

The patient's right upper and lower extremity weakness and numbness resolved. The patient also reported that they had experienced similar symptoms 3 years ago that resolved and work-up did not show any findings. According to the Rehabilitation Medicine consult, the patient had normal motor function, no speech impairment, no language impairment, and no cognitive impairment.

The Milliman Care Guidelines indicate inpatient admission for: Hemodynamic Instability, Focal Neurologic signs recur, Finding on brain imaging that requires inpatient care (e.g., mass), Altered mental status, Cardiac arrhythmias of immediate concern, Clinically significant cardiac or vascular disorder identified (e.g., on echocardiogram, imaging) that requires inpatient care (e.g., severe valvular disease, atrial myxoma, arterial dissection), Severe hypertension, Prolonged cardiac telemetry monitoring needed (e.g., beyond observation care time frame), Suspected vasculitis, Pregnancy, and Parenteral anticoagulation.

According to the medical records submitted for review, the patient did not have an indication that warrants inpatient admission. There was no hemodynamic instability, altered mental status or a Clinically significant cardiac or vascular disorder identified that requires inpatient care. 

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

Diagnosis: unintentional weight loss
Treatment: inpatient stay
the insurer denied the inpatient stay.
the health plan's determination is upheld. 

The patient is a female with a past medical history of anemia who presented for evaluation of unintentional weight loss, loss of appetite, and difficulty swallowing. On arrival to the emergency department (ED), she was afebrile, blood pressure was 98/51, heart rate was 60 beats per minute (bpm), respiratory rate was 16, and pulse oximetry was 97% on room air. Initial labs were notable for sodium 137, potassium of 4.3, blood urea nitrogen (BUN) of 9, and creatinine of 0.59. White blood cell (WBC) count was 3.3, hemoglobin was 5.5, hematocrit was 18.9, and platelet count was 419. She was admitted to the inpatient unit and was evaluated by gastroenterology. 

The inpatient hospital admission was not medically necessary. The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ Mal perfusion. There was no evidence of acute coronary syndrome. EGD and colonoscopy did not demonstrate any evidence of acute bleeding. There was no evidence of pericardial tamponade on her echocardiogram. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enterocolitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has a history of alcohol abuse and presented with abdominal pain and vomiting. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A sonogram showed a distended gallbladder with sludge but without stones. A computed tomography (CT) scan revealed an enterocolitis. The liver enzymes were elevated. Stool testing was ordered. A seizure disorder was treated. Antibiotics were given for the enterocolitis.

Clinical indications for admission for Gastroenteritis (Milliman Care Guidelines [MCG] M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetics, severe electrolyte abnormalities, hemolytic uremic syndrome, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bowel perforation or obstruction, and bacteremia. The patient did not have these conditions.

This patient had a history of alcohol abuse and liver disease. The patient now presented with gastroenteritis. Intravenous (IV) hydration and proton pump inhibitor (PPI) therapy could have been given with observation care. The patient was not in acute liver failure. The liver enzymes could have been monitored as an outpatient. If antibiotics were felt to be necessary for the enterocolitis, the patient could have been treated with them as an outpatient. The patient did not meet MCG criteria for admission for either gastroenteritis of Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Osteoarthritis, secondary malignant neoplasm of the bone, age-related physical debility
Treatment: Personal Care Aide (PCA), 24 hours/day, 7 days/week
The insurer denied coverage for PCA, 24 hours/day, 7 days/week.
The denial is overturned, in part.

The patient is an elderly male who lives with his spouse in a 1-bedroom apartment on the 5th floor. The patient is diagnosed with primary generalized osteoarthritis, secondary malignant neoplasm of the bone, age-related physical debility, decline, muscle weakness generalized, abnormalities of gait and ability, essential tremors, personal history malignant neoplasm of the prostate, personal history of antineoplastic chemotherapy, presence of other vascular implants and grafts, presence of cardiac pacemaker, coronary artery disease (CAD), hypertension (HTN), dizziness, fatigue, chronic pain, hearing loss and deficits of endurance, physical mobility, and ability to carry out activities of daily living (ADLs). Due to his overall health condition, the patient requires assistance with bathing, cleaning, shopping, laundry, cooking, and with all household chores. According to the comprehensive community health assessment, the participant needs help with meal preparation, housework, bathing, personal hygiene, dressing upper and lower body, walking, locomotion, toilet transfer, medication, and bed mobility. The patient had a recent fall, sustained a broken hip, and underwent surgery and inpatient rehabilitation. On the day of discharge home, he suffered another fall, injuring the left knee. 

The patient can no longer independently perform ADLs. The patient needs assistance with meals and medication, repositioning bi-hourly to prevent pressure ulcers. The appeal requested 2 split shifts of 12 hours daily, 7 days/week for the participant. 

The plan partial approval was for 10 hours/day, 7 days/week.

Based on the assessment and clinical documentation, the participant's needs can be sufficiently provided with 91 hours/week live-in. As per the documentation, due to significant decline in physical ability and recent injuries he needs support in all ADLs. 

The approved 10 hours/day, 7 days/week is not sufficient to support the participant's required care needs and maintain safety within his community. As such, the request Is modified to provide 91 hours/week live-in.

Based on the above, the insurer's denial must be overturned, in part. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for Personal Care Aide, 24 hours/day, 7 days/week services is not substantiated. However, 91 hours/week live-in is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned.

The patient is a teenage male. The request is for orthodontic benefits, including monthly visits. The patient has maxillary and mandibular spacing and a Class II malocclusion. The health 
plan denied coverage of the request due to a handicapping index score of 18 points. The denial is being appealed.

The requested health service is medically necessary.

The patient has a severe overjet of more than 9 millimeters and a deep, impinging overbite with trauma to the palatal tissues. Both of these conditions are automatic qualifiers for orthodontic benefits. Orthodontic treatment is needed to correct this patient's malocclusion, and the monthly visits are needed to make sure treatment is progressing properly. This case has medical necessity.