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

Diagnosis: Other - wound on bottom
Treatment: Skin protection cushion for wheelchair
The health plan denied: Skin protection cushion for wheelchair
The determination is: Overturned

The patient is a male being prescribed durable medical equipment (DME) for a skin protection cushion for a wheelchair for the diagnosis of wound on bottom. Coverage for the DME was denied by the health plan, and this denial is the subject under review.
Office visit notes were provided for review. The patient has a medical history notable for obesity, type 2 diabetes mellitus, hypertension, hyperlipidemia, seizure disorder, mild mental retardation, and depression. He has mobility impairment due to obesity and arthritis. He has a chronic open fistula below the coccyx and the "current cushion on his chair seat is thin and without flex to accommodate the wound" which is leading to excess pressure. He is under the care of a physician for the chronic wound. The wound was not examined at the office when the new cushion was prescribed.
Physical therapy notes were provided for review. They note an open area on the buttocks. The therapist recommends a seat that will provide skin protection and positioning.
At issue is the medical necessity of a skin protection cushion for the wheelchair.
The health plan's determination of medical necessity is overturned in whole.
The requested DME (skin protection cushion for wheelchair) is medically necessary for this patient.
The documentation provided indicates that the patient has a wound on the buttocks related to a chronic fistula. The wound is irritated by the patient's current cushion. It is medically necessary and reasonable to provide the patient with a cushion that will provide the appropriate support and offloading of the area with the wound. Failure to provide the appropriate cushion could result in worsening skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Side/Back Pain (Kidney Stone).
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male status post cholecystectomy with known renal stone of approximately three weeks duration who presented to the emergency department with flank pain, nausea and vomiting. The patient was known to have a 1.3-centimeter stone at the ureteropelvic junction with hydronephrosis. 
The patient was afebrile with an elevated blood pressure (BP) of 142/67 at presentation. Physical examination revealed right costovertebral angle tenderness and uncomfortableness. Computed tomography (CT) scan confirmed a 1.3-centimeter stone with hydronephrosis. The patient received intravenous ketorolac 15 milligrams for two doses and morphine four milligrams for one dose and Zofran four milligrams with pain control. The patient's white blood cell count was 5.3, serum creatinine was 0.92, urinalysis was negative for blood, negative for leukocyte esterase, no white blood cells, and negative nitrites. Urology was consulted with recommendation of admission and plan for cystoscopy, stent placement. Five months ago, the patient underwent cystoscopy and stent placement and was discharged to home that day. Acute inpatient admission was denied as not medically necessary as the patient did not meet renal colic and kidney stones criteria.

The proposed treatment was not medically necessary.

The patient presented with severe pain, nausea and vomiting with a known 1.3-centimeter stone in his ureteropelvic junction associated with hydronephrosis. The patient was treated with pain medication, Zofran and intravenous fluids and his pain was controlled. His white blood cell count was normal, he was afebrile, hemodynamically stable, had normal renal function, urinalysis without signs of infection and had no documented co-morbidities that required inpatient care. The procedure performed, cystoscopy and stent placement, does not require inpatient preoperative or postoperative care. Thus, the patient could have been managed at a lower level of care. The patient did not meet the Milliman Care Guidelines (MCG) Renal Colic and Kidney Stones criteria included as the patient has two kidneys, only one kidney was obstructed, no evidence of acute kidney injury (AKI) or acute renal failure, has not undergone renal transplantation, pain improved with pain medication in the emergency room, was not reported to have intractable vomiting in the emergency room, did not have a urinary tract infection, was not previously managed by observation with failure, and stone procedure did not require inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

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

This is the case of a previously healthy female who presented to the emergency department (ED) with a 1 day history of nausea, vomiting, diarrhea, and abdominal pain. There were at least 12 episodes of vomiting and 2 bouts of diarrhea reported. The patient ate pizza before the onset of symptoms. She was unable to tolerate any oral intake at home.

The inpatient hospital stay was not medically necessary for this patient. Based on the medical records provided, a lower level of care is appropriate.
This otherwise healthy teenager presented with acute gastroenteritis and subsequent dehydration. The patient's symptoms improved while receiving intravenous fluids (IVF) in the emergency department (ED), though she remained tachycardic which warranted additional IVF hydration. Given the expected short duration of stay and no need for additional work-up, a lower level of care is most appropriate for this individual.
Considerations for full inpatient admission include significant ongoing losses, inability to tolerate oral fluids, hypoglycemia or significant electrolyte abnormalities, or a medical condition requiring inpatient care. These were not present in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic obstructive pulmonary disease (COPD), diabetes and ulcerative colitis

Treatment: consumer directed personal assistance services (CDPAS) 12 hours per day, 3 days per week, for a total of 36 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 12 hours per day, 3 days per week, for a total of 36 hours per week

The denial is overturned

 

This is an elderly patient with medical problems including chronic obstructive pulmonary disease (COPD), diabetes and ulcerative colitis.  He lives alone in a private residence.  The patient is currently approved for consumer directed personal assistance services (CDPAS) 30 hours per week 10 hours/day, 3 days/week and personal care services (PCS) 40 hours per week 10 hours/day, 4 days/week.  He is requesting CDPAS 36 hours/week (12 hours/day, 3 days/week).

The recent Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as moderately impaired.  He is reportedly totally dependence for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is also reportedly totally dependent for bathing, personal hygiene, dressing, locomotion and toilet transfer/use.  Maximal assistance is reportedly needed for bed mobility and extensive assistance for eating. The patient is incontinent of bladder and bowel.  There has been no significant functional decline or reported falls over the prior 90 days; however, the patient is non-ambulatory.  He is essentially bed bound and totally dependent with significant cognitive deficits.  The patient's condition (as documented by his treating physician) and functional deficits are at a level or unpredictable as to require the requested CDPAS 36 hours/week (12 hours/day, 3 days/week).  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by the requested CDPAS 36 hours/week (12 hours/day, 3 days/week). 

Based on the above, the insurer's denial must be reversed. 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 consumer directed personal assistance services (CDPAS) 12 hours per day, 3 days per week, for a total of 36 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: nummular dermatitis
Treatment: Photochemotherapy
The insurer denied Photochemotherapy
The health plan's determination is overturned. 

The patient is a female with Prurigo Nodularis (PN) associated with nummular dermatitis due to intense pruritus on her lower legs. The patient has tried and failed topical steroids and tacrolimus, as well as oral antihistamines and intralesional Kenalog injections. The patient has developed bacterial infections and abscesses requiring treatment with topical and oral antibiotics. The patient has needle phobia and wants to avoid Dupixent that may affect her immune system.

Photochemotherapy is medically necessary for this patient. Phototherapy is one of the most medically safe, efficacious, and sustainable treatments for this challenging and life-disrupting (if not destroying) condition of constant and acute itching.
Prurigo Nodularis is one of the most severely pruritic and life-altering variants of atopic dermatitis and might in fact for some patients be a slightly different form of skin disease than atopic dermatitis. Even with Dupixent, the results take longer than usual for cases of Prurigo Nodularis than for most atopic dermatitis patients, and often might require one or more topical or even systemic therapies (including light therapy) used concurrently with Dupixent. Narrowband UVB is very often a successful monotherapy for both Prurigo Nodularis and for the pruritus caused by liver, renal, senile, or human immunodeficiency virus (HIV) -related pruritus. Narrowband UVB is therefore often used as first- or second-line systemic therapy for Prurigo Nodularis and is a medically appropriate and necessary treatment for patients with this challenging condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issues (including crossbite). 
Treatment: Full Braces and Monthly Brace Adjustment Visits. 
The insurer denied Full Braces and Monthly Brace Adjustment Visits. 
The health plan's determination is overturned. 

The patient in question is a male. He is class II with a blocked out maxillary left first premolar (tooth #13). The lower midline is shifted to the right and teeth #4 and #13. He has a functional shift to the right. He is treatment planned for Full Braces and Monthly Brace Adjustment Visits. 

Full Braces and Monthly Brace Adjustment Visits are medically necessary for this patient. 
This patient presents with crowding and partially blocked out tooth #13. Most significant is the posterior crossbite and corresponding mandibular midline shift to the right. There is strong medical evidence that early correction of posterior crossbites with a shift reduces the need for future treatment. The evidence shows if such a crossbite is not corrected before the patient reaches skeletal maturity, the ability to achieve orthopedic expansion is greatly reduced. Given this patient's age, he is nearing the end of the time that orthodontics alone can correct his crossbite. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented to the emergency department (ED) complaining of chest pain. Her medical history was remarkable for diabetes, hypertension, hyperlipidemia, heart failure with preserved ejection fraction, chronic hyponatremia and end-stage renal disease on hemodialysis. The patient reported missing her scheduled dialysis session. The patient complained that her abdomen felt "funny". An abdominal x-ray showed gastric distension. She was treated with intravenous furosemide and morphine and was admitted to the hospital to rule out acute coronary syndrome. She had no further chest pain. The patient underwent dialysis with increased sodium in the dialysis bath and salt tablets were prescribed. Surgical consultation was obtained for her abdominal distension. A nasogastric tube was placed to suction and an abdominal computed tomography (CT) scan was recommended. This showed no bowel obstruction and evidence of chronic constipation. An echocardiogram showed left ventricular hypertrophy, normal left ventricular systolic function and grade I diastolic dysfunction. The patient underwent her scheduled dialysis. She was discharged. At issue is the medical necessity of an inpatient stay.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS). Observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with no ischemic electrocardiographic changes. Her initial cardiac troponin level was normal. A repeat level was minimally elevated without a significant delta troponin and based on her renal disease, was not diagnostic of myocardial injury. She did not require intensive monitoring, infusion of intravenous cardioactive medications or urgent cardiac catheterization. The care this patient received for her chest pain did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline
for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient diagnosed with hyperglycemia. He has diabetes, dyslipidemia, hypertension and acute kidney injury (AKI). The patient was admitted to the emergency room (ER) with a high blood glucose level in the 400s, nausea and vomiting and abdominal pain, polydipsia, and polyuria. The patient was given insulin and metformin as an outpatient but was not controlled.
In the emergency room (ER), his glucose was 585, creatinine 1.53, urine ketones 15, anion gap 16, point of care testing (POCT) 50, potential hydrogen (pH) 7.38, Total carbon dioxide (CO2) 31. He had ketosis and failed outpatient management. The patient was admitted due to a concern of diabetic ketoacidosis (DKA) and dehydration. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary. The patient was given insulin and metformin as an outpatient but was not controlled. The patient was monitored until his blood glucose (BG) was controlled. He had diabetes education and nutritionist support. He was discharged on a diabetic treatment plan.  Diabetes education consists of several components, nutritional counseling, self monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1,2). Practice patterns differ depending on the availability of educators. Whether a patient is hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen. The majority (75 percent [%]) of medical centers in the United States (3) that treat new onset diabetes admit their patients. According to the American Diabetes Association (ADA) statement on treatment of diabetes (4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education." There are no randomized controlled trials comparing inpatient to outpatient diabetes education in type 2 diabetes. A patient with polyuria, polydipsia, ketosis and a glucose in the 400s who failed outpatient management, should receive rehydration and insulin therapy to achieve the fastest and best control of their diabetes(5-8). The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is the case of a patient that presented to the hospital complaining of chest tightness, palpitations, and dyspnea on exertion. Past medical history was significant for atrial fibrillation, hypertension, heart failure with preserved ejection fraction and gastro esophageal reflux disease. On arrival to the hospital, vital signs were stable (Blood Pressure 146/79, Pulse 89). Physical examination revealed a body mass index (BMI) of 41 without significant abnormality. 12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with premature atrial beats, prolongation of QTc (interval on ECG) at 471, and non-specific ST (interval on ECG) changes in leads I, aVL, V5 and V6. Serum blood testing demonstrated an elevated troponin of 27. COVID (Coronavirus) testing was positive. The patient was chronically treated with sotalol therapy and was not a candidate for Paxlovid. The patient was admitted to the hospital and treated with remdesivir anti-viral therapy. Telemetry revealed paroxysmal atrial arrhythmia and occasional ventricular premature beats. The patient remained stable and was discharged home with follow up.

This patient presented to the hospital complaining of chest pain with an elevated troponin and prolonged QTc interval on ECG. The patient was treated for atrial fibrillation with sotalol therapy and was infected with the COVID virus. This patient had a low pretest probability of coronary artery disease. (1) This patient required acute inpatient admission for monitoring and treatment of chest pain in the setting of coronavirus. Myocarditis and pericarditis have been well described in patients presenting to the hospital with COVID-19 infection. (2-4) In one study of patients hospitalized for COVID-19 infection almost 20% (percent) of patients had a prolonged QT interval on ECG. Almost 2% of patients in this cohort had ventricular tachycardia or ventricular fibrillation. The authors noted that patients presenting with acute cardiac injury had an elevated mortality rate. (2) In addition to an abnormal ECG, this patient required treatment with remdesivir for COVID-19 infection. In a study of patients presenting to the hospital that were treated with remdesivir, the average length of stay was 6 days (5). In conclusion, inpatient hospital admission was medically necessary to monitor and treat chest pain in the setting of COVID-19 infection.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a woman who was admitted to the hospital with a painful right leg and edema for four days. The pain progressed, despite no definite trauma. There was no chest pain, shortness of breath, or change in exercise tolerance. Examination revealed normal temperature, heart rate of 90, and blood pressure of 114/70, with saturation of 100% (percent) on room air. The examination revealed normal cardiopulmonary exam, 1+ right lower extremity edema with tenderness to palpation and slight warmth.

The inpatient hospital admission was not medically necessary. The documentation describes an uncomplicated deep vein thrombosis (DVT) in the setting of a 7-week pregnancy. The DVT is unilateral; the patient has normal creatinine clearance and can tolerate subcutaneous Lovenox injections. There is no documentation of liver disease or thrombocytopenia. The patient is early in her pregnancy, so monitoring for early delivery is not indicated in this setting. The patient is relatively healthy with no past medical history. She was anemic. It was reasonable to admit for observation, provide a blood transfusion, initiate anticoagulation, monitor for tolerance, and provide education. However, this is typically a 24-hour, up to 48-hour process and does not require additional monitoring or treatment in an inpatient setting. The documentation demonstrates the patient had no complications of anticoagulation initiation. There is no evidence of hemodynamic compromise, pulmonary embolism, or heart strain. This presentation was not deemed to be a pregnancy complication. Therefore, inpatient admission is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with medical history of human immunodeficiency virus on highly active antiretroviral therapy, asthma, hyperlipidemia, opioid use disorder on methadone, and breast cancer status postlumpectomy and radiation therapy. She presented to the emergency department with watery diarrhea for four days, vomiting, and abdominal pain. Vital signs were notable for unremarkable blood pressure of 104/74, pulse of 91/minute, and temperature of 36.9 C (Celsius). Physical examination was notable for dry mucous membranes, and tenderness to palpation along the lower abdomen without rebound or guarding. 

Inpatient Hospital Admission was not medically necessary for this patient.
The patient had a finding of Clostridioides difficile infection with colitis on imaging; however, there was no sustained hypotension, persistent severe volume depletion or sepsis, toxic megacolon, or other reasons for the inpatient level of care such as perforation or abscess. Although uncomplicated Clostridioides difficile infection was present, the patient did not have persistent gastrointestinal bleeding, peritonitis, or other complications warranting inpatient level of care. She was appropriately started on treatment for Clostridioides difficile infection with oral vancomycin, and subsequent symptomatic improvement. The standard of care for the evaluation of Norovirus was appropriately performed, including intravenous fluids and supportive care. Although she had human immunodeficiency virus, her disease was well-controlled on therapy, and there were no complicating factors which would support the inpatient level of care. The measures which were undertaken, including observation, labs, antibiotic administration, Infectious Disease consultation, and gradual advancement of diet, could have been performed at a lower level of care.