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

Diagnosis: idiopathic Short Stature
 
Treatment: Medication coverage

The insurer denied the medication coverage. The denial was reversed.   

This is an adolescent female patient followed for short stature since early 2017 when her height = 48.7" (123.7 cm, - 3.83 standard deviation score [SDS]) and her weight = 43.7 pounds (-5.24 SDS) giving her a Body Mass Index (BMI) = 12.95kg/m2 (-3.23 SDS).  Her height velocity = 0.7 cm/year.  Bone age at a certain age was that of a child a few years younger.  Growth Hormone (GH) stimulation testing in mid-2017 demonstrated a peak of 14.1 ng/ml.  Her Pediatric Endocrinologist made a diagnosis of idiopathic short stature and started her on growth hormone (GH) therapy, to which she has demonstrated an excellent response with growth rates as high as 10 cm/year.  Her new insurer has declined to continue paying for GH therapy, stating that she does not meet medical criteria for that diagnosis as she has not failed two GH stimulation tests and had an MRI.
The patient meets medical criteria for use of growth hormone therapy for a diagnosis of idiopathic short stature with a height more than -2 SDS below the mean for age, having passed growth hormone stimulating testing with a peak level of 14 ng/ml, and growing at a growth velocity unlikely to result in the attainment of normal adult height.(1,2)  In the absence of pituitary hormone abnormalities and neurological abnormalities, there is no basis for requiring an MRI study.  "If a diagnosis of Idiopathic Short Stature [ISS] is made, magnetic resonance imaging is not indicated."(2)  The patient therefore meets criteria for use of growth hormone therapy for the treatment of idiopathic short stature.

The carrier's denial of coverage for Omnitrope 10mg per 1.5ml cartridge, nine every 30 days is reversed.  The medical necessity is substantiated
Appeal type: Medical necessity
Decision: Overturned

This is a patient with impacted tooth number (#) 11 and an anterior crossbite of #10. She presents with a skeletal Class I malocclusion and significant crowding. She is treatment planned for orthodontics to address the crowding and impacted teeth. The health plan's determination is overturned.
This patient is treatment planned for orthodontics to address the crowding and impacted teeth. Impacted teeth are common and they often cause pathology 1. Since this patient has an impacted canine, it is medically necessary to treat with orthodontics to address the situation and prevent likely future dental problems associated with an untreated impacted tooth. If left untreated the damage that can occur to the patient's teeth will be more time consuming and to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisor.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female with a past medical history significant for endometrial polyp who presented to the emergency department with a 6-day history of intermittent episodes of non-bloody, non-bilious vomiting as well as a 4-day history of right lower quadrant abdominal pain. The patient was unable to eat, drink, or take oral medications because of persistent nausea or vomiting. Subsequently, the patient was suspected to have PID/Fitz-Hugh-Curtis syndrome and received treatment with intravenous (IV) antibiotics. The patient required an admission at the inpatient level of care, due to the inability to tolerate oral intake, oral antibiotics, persistent nausea, and vomiting. It was documented on several occasions that the patient did not tolerate oral intake for several days. Therefore, the administration of intravenous antibiotics was warranted, in addition to serial abdominal exams.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hepatitis B on anti-viral treatments and not associated with cirrhosis, who presented to the emergency department with a chief complaint of vomiting bright red blood and dizziness. He had been seen in the emergency department earlier in the day with epistaxis and had been sent home. The patient denied nausea, abdominal pain, bright red blood per rectum, constipation, or other complaints.

On presentation to the emergency department, he was noted to have vital signs within normal limits. Exam otherwise was notable for guaiac positive stool. Epistaxis was noted to have stopped in the emergency department without intervention. The health plan's determination is upheld. This patient presented with epistaxis and a hemoglobin of 10.6. He had had one prior episode earlier in the day that self-resolved. He subsequently presented to the emergency department with a second episode of epistaxis that was accompanied by dizziness and vomiting and which had resolved again by the time he reached the emergency department. His exam did not note any evidence of active bleeding at time of presentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weakness
Treatment: Inpatient admission
The proposed treatment inpatient admission is deemed medically necessary. 
This is a female patient who presented to the emergency room (ER) for further evaluation/management of weakness. Intake vitals were noted to be afebrile, hemodynamically stable. Examination was non-focal with no significant abnormalities noted. Laboratory testing was notable for an elevated troponin level and critically depressed hemoglobin level of 4.1. The patient was admitted to the inpatient medical service where she received three units of PRBC blood transfusion and underwent extensive GI evaluation including EGD / colonoscopy which was negative for active bleeding. She improved with the prescribed therapies and was subsequently discharged in stable condition. 

Evidence of critically depressed hemoglobin levels of 4.1 with need for emergent blood transfusion using multiple units of PRBCs and elevated troponin level requiring close monitoring to rule out potential acute coronary syndrome indicates an intensification of services during the course of this patient's hospital stay. Hence, the patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with chronic respiratory failure with hypercapnia status post a tracheostomy and feeding tube, functional quadriplegia, neurogenic bowel & bladder and a stage 2 sacral decubitus ulcer requiring a wound vac. 
The health plan's determination is overturned. 

Per the patient advocate's letter , the patient is only receiving 91 hours/week of CDPAS and no skilled services are being provided.
The patient was determined to have a stable medical condition that is not expected to deteriorate suddenly and the patient is self-directing and able to follow commands and make appropriate choices, she would require help with activities of daily living such as making beds, house work such as dusting/vacuuming/dishwashing, shopping and laundry. In addition, she would also need full assistance with bathing and grooming, partial assistance with dressing, transfers from bed, administration of medications and using her rolling walker. Also per criteria; "Live-in 24-hour personal care services. The scope of the PCS benefit includes live-in 24-hour personal care services which means the provision of care by one person for a member who, because of the member's medical condition and disabilities, requires some or total assistance with one or more personal care functions during the day and night and whose need for assistance during the night is infrequent or can be predicted and where the assessment determines that the member's home has adequate sleeping accommodations for the personal care services worker. The live-in 24 hour personal are services rate of payment is based on 12 hours of care." In this patient's case she needs help transferring from her bed to a rolling walker, frequent turning and assistance in toileting/grooming both during the day and night and additional help with activities of daily living. Therefore, the provision of 24-hours per day 7-days per week of personal care services would be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizure
Treatment:  Inpatient admission
The acute inpatient admission from 05/16/2019 through 05/18/2019 was not medically necessary. 

The patient is a male with a history of seizure disorder who presented to the emergency ward with confusion after a seizure.  He received parenteral phenytoin and was admitted for prolonged post ictal confusion. 

The next day, the patient was no longer confused, and he had no recurrent seizures. 

The patient was restarted on phenytoin and had returned to his baseline neurological status.  He did not require acute inpatient care and management could have been achieved at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient , with a past medical history significant for non-ischemic cardiomyopathy that was attributed to uncontrolled hypertension, morbid obesity, obstructive sleep apnea, and medical noncompliance. The patient presented to the emergency department with an episode of shortness of breath that woke her up from sleep.The health plan's determination of medical necessity is upheld in whole. During the admission, the patient did not require endotracheal intubation and mechanical ventilation. There was no evidence that the patient had an acute coronary syndrome, life-threatening arrhythmia, pulmonary embolism, or aortic dissection. In general, the patient's clinical condition normalized very quickly. Considering these circumstances, the care could have been provided in a lower level of care setting, as there was quick resolution of the symptoms, in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intentional drug overdose
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

Following this patient's ED evaluation, she was clinically stable. She had ingested several Klonopin approximately ten hours earlier. She was not showing any signs of severe benzodiazepine toxicity. She was sleepy, but easily arousable. Her vital signs were normal. Her blood work did not reveal any abnormalities. She was still suicidal. The admission note for this patient indicates that she would be kept under constant observation. A psychiatric consultation was planned for the patient. She would be kept on a monitor for the rest of the day to watch for any respiratory depression. No other testing or consultations were described for the patient in her admission note.

At the time this patient was admitted, it would have been reasonable to believe that this very limited plan of care could be accomplished for a stable patient with a very short stay in the hospital. She had presented to the hospital ten hours after her overdose and was not showing any signs of serious benzodiazepine toxicity. It was likely that she could be transferred to the psychiatric service the following day. For this reason, an inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

There was no severity of illness present to justify an inpatient admission. The patient had normal vital signs and normal mental status. There was no intensity of services required for this patient to justify an inpatient admission. She required constant observation. She required cardiac monitoring overnight.

In conclusion, the inpatient admission was not medically necessary. The patient was clinically stable following her ED evaluation. A limited plan of care was anticipated for her. She could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol Withdrawal Seizure
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was reversed.  

This is a male patient was admitted to inpatient hospital in early 2019 due to a seizure in the context of alcohol withdrawal that lasted five minutes; he stated he had a prior seizure a month earlier and experienced a recent head injury.  He reportedly had tremors, and nausea, and a blood pressure of 184/94.  He had hyponatremia, low Magnesium, low Chloride, prolonged QT and T wave abnormalities, macrocytic anemia, and severe thrombocytopenia.  He was noted to have had altered mental status and was given intravenous (IV) medications including Librium for detoxification.  He reportedly was discharged the next day. 
This was the case with this patient as he had reports of alcohol withdrawal seizures and multiple medical issues.  It did not appear that this patient could safely and effectively be treated in a less restrictive level of care, as he had active withdrawal symptoms including altered mental status and could only take medication intravenous (IV) including his detoxification medication (Librium).  
According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment, as he could not safely and effectively be treated for detoxification in a less restrictive setting, as he needed detoxification medication to modify withdrawal from alcohol, and he needed 24-hour treatment then, as he was at risk for even worsened withdrawal symptoms if not in this 24-hour setting then, including possible life threatening withdrawal such as delirium tremens.  This patient had multiple medical problems and could not safely and effectively be treated in an outpatient detoxification setting and required 24-hour inpatient medical hospital detoxification treatment then.  He was considered a high risk medically. 

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal Delirium and Influenza.
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.   

This is a middle aged male was admitted to inpatient hospital level care in early 2019 due to alcohol withdrawal symptoms including tremors which worsened, multiple vomiting episodes, nausea, and sleeping problems. He also had chest pain, shortness of breath, dizziness, cough, and a sore throat. It was reported that he has a 30 year history of drinking alcohol. He had multiple medical issues including Chronic Obstructive Pulmonary Disease, hypertension, and lung cancer and was getting chemotherapy. He tested positive for influenza and was given Tamiflu. He took Ativan 2 mg once during this admission, his primary diagnosis was alcohol withdrawal delirium and then influenza. He also received IV fluids. He reportedly had a similar episode a few months prior to admission. He was then discharged.

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he was drinking large amounts of alcohol despite multiple medical issues including COPD, hypertension, lung cancer on chemotherapy, and he had influenza as well. He reportedly could not maintain abstinence on his own as he had a 30 year history of drinking alcohol. He required detoxification medication to modify withdrawal as he was in active withdrawal, thought to possibly have delirium. He needed 24 hour medical inpatient hospital treatment for safe detoxification. He was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including life threatening delirium tremens. It was reported that he had detoxification medication during hospitalization. Even though he did not report further withdrawal symptoms during this admission, the risk of life complicated withdrawal, delirium tremens can occur 3-4 days after alcohol use. His past and current medical issues interfered with the ability to have safe and effective detoxification in an outpatient setting. He required inpatient medical hospital treatment. 

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.


This is an elderly female who presented to the emergency room (ER) in late 2018 with a 1-day history of left lower abdominal/flank pain with nausea; she denied vomiting. Initial vital signs were:  temperature 97.7; heart rate 67; respirations 20; blood pressure 133/80. The patient had normal bowel sounds; there was moderate tenderness in the left lower quadrant; a rebound tenderness exam was negative.  Labs were normal, per ER physician. Urinalysis was negative. CT scan of the abdomen and pelvis revealed no acute findings.  The patient continued to report left lower quadrant pain for which she was given intravenous analgesics. She was started on Miralax, proton pump inhibitor (PPI) therapy, and Dicyclomine. The pain improved.

Clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an outpatient basis or peritoneal signs. 
The patient did not have these conditions. She also did not have hemodynamic instability, intestinal obstruction, bacteremia, a severe electrolyte abnormality, or an inability to maintain oral hydration. This patient had abdominal pain that may have been related to constipation
Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Seizures
Inpatient Stay

This is a patient who was admitted to the hospital with a history of seizures.  He was on Dilantin and Keppra, and he presented after a seizure. His triggers included the smell of bleach, markers, and solvents. He reported that he never had seizures in the absence of these triggers. According to his brother, he had shaking movements but no tongue biting or incontinence. He denied fevers and chills. On physical examination, he was in no distress, his heart was regular, breath sounds were normal, and there were no cranial nerve deficits.  An electrocardiogram (EKG) showed normal sinus rhythm.  
The health plan's determination is upheld. This patient was admitted for a seizure. The plan of care included a neurology consult, neurochecks, continuation of Keppra, and intravenous (IV) fluids. A neurologist saw the patient and recommended continuing his current therapy and following up as an outpatient.  The patient had an uncomplicated episode of a seizure and a history that was consistent with a known seizure trigger. There was no evidence of infection, meningitis, hemodynamic instability, ingestion, nonadherence to medications, or acute recurrent seizures. This was an uncomplicated presentation and did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension, diabetes, hyperlipidemia and coronary artery disease. The patient has previously undergone coronary artery bypass graft surgery; and several percutaneous coronary interventions. Recently the patient had cardiac stress testing with myocardial perfusion imaging for complaints of recurrent chest pain. The request is for PET scan. The health plan's determination is overturned.

An outpatient cardiac PET scan is medically necessary in this instance. This patient, with known coronary artery disease, has chest pain and had an abnormal nuclear stress test with Single-photon emission computed tomography (SPECT) imaging. The quality of the study was poor due to that patient's body habitus. It could not be determined if there was inferior ischemia or if the abnormality was artifactual. Thus, further testing is needed. Options for arriving at a definitive diagnosis include conventional coronary angiography, which is invasive; coronary computed tomography (CT) angiography, which provides anatomic but no functional information; and cardiac PET scanning. PET myocardial perfusion imaging (MPI) is considered the most accurate noninvasive means for detecting functionally significant coronary artery disease. Compared to SPECT imaging, cardiac PET has higher spatial resolution and, unlike SPECT, allows for attenuation correction, which is important in cases where body habitus and adiposity negatively impact image quality. In comparison studies, its diagnostic accuracy is superior to that of gated SPECT images. Thus, it is medically necessary in this instance to determine whether or not the patient's chest pain is due to angina, and to guide therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Depression
Treatment:  Continued inpatient admission 
The continued inpatient admission was medically necessary.  

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of paranoia and suicidality with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  
The patient represented an elevated risk of dangerous behaviors including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained with acute symptoms including paranoia and suicidality.  The patient had multiple static risk factors for potentially dangerous behaviors including prior suicide attempts and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained symptomatic was an acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.