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

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male who presented to the emergency department after he had a seizure. The seizure was witnessed by his girlfriend who said that the patient had experienced generalized shaking movements with upward rolling of the eyes and foaming coming from his mouth.

The patient was admitted to the hospital with the diagnosis of a new-onset of seizures. The admitting physician reported that a computed tomography (CT) scan of the head that was performed in the emergency department was unremarkable.
Electroencephalogram (EEG), magnetic resonance imaging (MRI) of the brain, creatine phosphokinase (CPK) levels were ordered.
MRI of the brain was unremarkable. The patient was evaluated by a neurologist who suggested that there was no need for anticonvulsant medication. The neurologist also recommended EEG to be performed as an outpatient. Since the patient remained in stable clinical condition, he was discharged home.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
Based on the accepted standards of care, admission at the acute inpatient level of care is generally indicated for patients with seizures and hemodynamic instability, status epilepticus not controlled with emergent treatment, presence of brain disorders such as a tumor, edema, trauma, hydrocephalus, encephalitis, meningitis.
The admission at the acute inpatient level of care is also indicated in cases when the seizures are caused by drug toxicity, withdrawal, or non-adherence to medications.
The admission at the acute inpatient level of care is also required in cases when seizures are associated with cardiac arrhythmias of immediate concern, severe or persistent altered mental status, presence of focal neurologic deficits, metabolic abnormalities that persist despite observation care treatment, cases of recurrent seizures, certain cases when outpatient anti-seizure regimen could not be established, or cases of cerebral bleeding, hydrocephalus, or need for vasospasm monitoring, or in cases of increased intracranial pressure or cerebral edema monitoring.
A careful review of the patient's records clearly demonstrated that the patient had none of the conditions listed above. During the entire hospital stay, this patient remained hemodynamically stable, seizure-free. His hospital stay was very short.
The patient could have been managed at a lower level of care status. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male who presented to the emergency department (ED) with severe dizziness for 2 weeks and two episodes of vomiting. He also had blurry vision for 4-5 hours. His blood pressure was elevated. With the first episode the patient went to outpatient clinic and was referred to ED, but he did not go. His dizziness worsened on the day of admission.
The patient has history of diabetes mellitus (DM), hyperlipidemia and prior history of stroke. His previous stroke left him with residual right sided weakness and hyperreflexia.

In ED, his blood pressure (BP) was 150/87 and heart rate (HR) 105 and respiratory rate (RR) was 18. The patient had intention tremor, jerky nystagmus, positive Romberg sign, and dysdiadochokinesia, inability to complete finger- to -nose testing on the right side. The rest of his physical examination was unremarkable. Laboratory results were remarkable for creatinine 1.1, blood urea nitrogen (BUN) 15. The rest of his labs were unremarkable, including troponin.
Electrocardiogram (ECG) revealed sinus rhythm. Chest x-ray was normal. CT head revealed mild central and cortical atrophy with chronic white matter ischemic changes and evidence of prior lacunar infarct in the pons. Carotid ultrasound was done and was normal.
The patient was treated in ED with hydration, famotidine, meclizine, promethazine and hydrochlorothiazide. The patient had episodes of recurrent vomiting times 4 in ED.
The patient was admitted to the hospital. The patient underwent echocardiogram. It revealed left ventricular hypertrophy (LVH) with ejection fraction (EF) 70-75 %. Left ventricular outflow tract (LVOT) gradient was 13 millimeters of mercury (mmHg). There was grade 1 diastolic dysfunction.
The patient underwent neurology evaluation.
The patient underwent brain MRI. It revealed numerous scattered foci of abnormal signal intensity in the periventricular and subcortical and deep white matter concerning for demyelinating disease. The patient was treated with multiple oral medications. His condition improved, his vomiting and dizziness improved, he was able to have normal oral intake.
The patient was discharged home.

The health plan's determination is upheld in whole.

The requested health service/treatment of Inpatient stay was not medically necessary for this patient. The patient with previous history of stroke presented with symptoms suggestive for new stroke. However, imaging studies did not support presence of acute stroke. He was established with a diagnosis of vertigo. He was given intravenous fluids (IVF) and oral medications. The patient recovered and was discharged.
The patient's condition and the level of care did not meet criteria for inpatient admission. He could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment Braces
The insurer denied the braces as not medically necessary.
The determination is upheld.

The patient has severe maxillary and mild mandibular crowding. Tooth number (#) 11 has erupted labial within the arch due to lack of space. The patient has a class I occlusion with a 6 millimeter (mm) overjet and 30% overbite. The patient is treatment planned for 24-30 months of orthodontics along with extraction of maxillary and mandibular first premolars to align the teeth and correct the bite but the plan was denied due to lack of medical necessity. At issue is the medical necessity of braces.

While the patient has crowded teeth, there is not anterior or posterior crossbite. There is no evidence of wear or periodontal recession. Sometimes patients have orthodontic problems that need to be fixed while the patient is still growing or it will be impossible to fix later. This patient does not have any of those orthodontic problems. (2)  She has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. (3) If her teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

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

The patient is a woman who was admitted to the hospital. She presented with intermittent abdominal pain over the past week. She stated that her pain started after she ate a pepper steak and she described the pain as involving the epigastric region. In addition, she said it was a dull pain that was aggravated by eating. She denied fevers and chills. Initial vital signs showed blood pressure 162/99, heart rate 88, and oxygen saturation 99% on room air. On physical exam, the abdomen was soft and tender to palpation. Labs showed white blood cell (WBC) 9.5, and lipase 377. A computed tomography (CT) of the abdomen was consistent with enteritis. Other labs showed hemoglobin 12.3, platelets 289, sodium 136, potassium 3.9, ionized calcium 4.5, aspartate aminotransferase (AST) 185, alanine aminotransferase (ALT) 122, and Troponin 0.01. The patient was admitted with enteritis. 

The inpatient stay was not medically necessary. The reason is that the patient presented with a non-severe case of enteritis, with elevated liver enzymes and elevated lipase. She had no evidence of sepsis, no evidence of hemodynamic instability, did not require high-dose IV opioids, and had no imaging findings requiring more intensive care or surgical intervention such as a pancreatic pseudocyst or an abscess. The patient could have been managed at a lower level care, considering that she was hemodynamically stable, did not require a surgical intervention, and did not have sepsis. This is also consistent with her short hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Infectious disease
Inpatient hospital

Diagnosis: Fever
Treatment; Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented to the emergency department with fever without a source. He was well until 3 days prior to presentation when he developed a cough and fever. His temperature went up to 102 F at home. He had decreased activity and decreased oral intake, with only 3 wet diapers over 24 hours. He was therefore brought to the emergency department for evaluation.

The inpatient stay was medically necessary.
This is an infant who presented with a high fever and no focal source, as well as decreased activity and decreased oral intake. There was concern for cardiomegaly on his initial chest x-ray (CXR), and leukocytes on his urinalysis raising concern for a urinary tract infection. He required hospital admission for intravenous fluids, specialist consultation, and close monitoring while cultures were pending with additional treatments as needed. Both myocarditis and possible sepsis are serious conditions in young infants that require prompt evaluation and treatment to prevent serious morbidity and even death.
The decision making at the time of admission for this patient was consistent with his young age, the presence of high fever without a clear source, and concerning findings of an enlarged heart on chest x-ray and pyuria suggesting possible serious infection.
According to the Milliman Care Guidelines (MCG), Pediatric, Sepsis and Other Febrile Illness; hospital admission is indicated for infants with febrile illnesses without focal infection if they have a finding that prompts suspicion of diagnoses of specific infection requiring hospitalization. This patient had high fever and concerning signs including cardiomegaly and pyuria that raised concern for serious infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a woman. Her medical history included asthma, tobacco-use, and schizophrenia. Her surgical history included Cesarean section. She presented to an emergency room with a three-day history of nausea, vomiting, and right-upper-quadrant abdominal pain.

The patient's vitals were as follows: temperature 36.8, pulse 68, blood pressure 125/76, respirations 18, oxygenation 96%. Physical examination demonstrated tenderness to palpation of the right-upper-quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 11.8. Abdominal ultrasound and abdominal computed tomography demonstrated cholecystitis.

The patient was admitted at an acute inpatient level of care with a diagnosis of acute cholecystitis. She underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated. For acute psychosis, the patient received psychiatric evaluation and treatment.

Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical and psychiatric follow-ups.

No, the Inpatient admission was not medically necessary.

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery".  Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission at an acute inpatient level of care. Moreover, her psychiatric evaluation and treatment could have been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Umbilical hernia with obstruction
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. Her medical history included hypertension, palpitations, obstructive sleep apnea, asthma, obesity, and umbilical hernia. Her surgical history included laparoscopic cholecystectomy. The patient presented to an emergency room with a four-day history of anorexia, nausea, vomiting, and abdominal distention and pain, stating, "My hernia popped out."

The patient's vital signs were as follows: temperature 98.4, pulse 120, blood pressure 171/84, respirations 20, and oxygenation 94%. Physical examination demonstrated diffuse abdominal tenderness to palpation and umbilical hernia. Serum laboratories demonstrated leukocytosis to 14.36. Computed tomography demonstrated "umbilical hernia" containing small bowel.

The patient was admitted at an acute inpatient level of care with a diagnosis of "Umbilical hernia with obstruction." She was made nil per os [NPO], and provided with intravenous fluids and analgesics.

The patient underwent "Incisional/ventral hernia repair with mesh." Surgery and recovery were uncomplicated.

Having returned to her baseline function and health, the patient was discharged home in good and stable condition with prescriptions for oral analgesics and outpatient surgical follow-up.

No, the Inpatient Admission was not medically necessary.

According to peer-reviewed medical literature, patients undergoing open ventral hernia repair have a median length of stay of four days. However, patients may be admitted at an observational level of care immediately after surgery, and be converted to an acute inpatient level of care if further medical-surgical hospitalization were warranted [Funk et al.; Goodney et al.; and Lee et al.].

Therefore, this patient could have been admitted and undergone surgery at a lower level of care. Had she needed an extended hospitalization, her admission could have been converted to a higher level of care. However, she did not require this, and she was discharged on post-operative day #1.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Protruded teeth
Treatment: Comprehensive Orthodontics
The insurer denied the Comprehensive Orthodontics.
The denial is overturned. 

Yes, the comprehensive orthodontics are medically necessary.

The patient's front upper teeth are extremely protruded forward. This will make them more prone to trauma and fracturing over time. These teeth need to be retracted with orthodontic treatment, which is medically necessary.

This patient has a need for his upper front teeth to be repositioned in order to prevent them from breaking. Orthodontic treatment is needed to do this, and the health plan did not determine the needs of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Amputation
Treatment: Prosthetics
The health plan denied the Artificial Leg as not medically necessary. 
The denial is overturned in whole.

The patient is requesting a replacement right transfemoral GeniumX3 microprocessor prosthesis secondary to right transfemoral amputation in childhood due to amniotic band syndrome in utero. He has worn a prosthesis nearly his entire life. Documentation noted that he lives an active lifestyle, including his job.

The requested artificial leg is medically necessary for this patient.
The patient has worn a prosthesis nearly his entire life. Documentation noted that he lives an active lifestyle. By definition, the patient is a K4 level amputee as his everyday lifestyle exhibits high impact, stress, and energy levels on his prosthetic. He works in heavy highway construction working both in office and on site. His job on site requires him to be on his feet for extended periods of time, traverse uneven terrain, submerge into water filled trenches, and climb steep slopes. The requested knee is the most appropriate, safest knee, for this patient and will allow him to complete his basic everyday needs without concern that his prosthetic will break from the stress of his active lifestyle.
Per documentation review, his current prosthesis is not waterproof and, therefore, he is unable to fully complete his job duties. The ability to complete his job requirements is a basic health need.  Documentation also noted that previous prosthetics that were not waterproof have been used in the past and resulted in damage to prosthetic devices.  Therefore, this reviewer opines that the requested GeniumX3 microprocessor prosthesis is medically necessary and appropriate for this specific patient, as the service meets accepted standards of medicine, and is necessary to meet the patient's basic health needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cognitive decline, chronic conditions.
Treatment: Increase Personal Care Services, Level II, to 12 hours per day, 7 days per week for a total 84 hours per week.
The insurer denied the Increase Personal Care Services, Level II, to 12 hours per day, 7 days per week for a total 84 hours per week.
The denial is upheld. 

This patient is a female requesting an increase in personal care service (PCS) hours. A letter from the attending physician (AP) notes the patient has several chronic medical conditions. The letter notes the patient needs ten  hours of care seven days a week due to rapid cognitive decline and physical debility and needs assistance with activities of daily living (ADLs) as well as fall prevention.  The patient lives alone.  She has a cane, walker, grab bars, shower chair, and incontinent materials.  Per recent assessment:  some cognitive difficulty in new situations; max assistance with meal prep, housework, and shopping; limited assistance with managing finances and medications, phone use, personal hygiene, upper body (UB) dressing, locomotion, and toileting; extensive assistance with transportation, bathing and lower body (LB) dressing; and independent with bed mobility and eating.

No, the proposed treatment, Increase Personal Care Services, Level II, to 12 hours per day, 7 days per week for a total 84 hours per week, is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient requires assistance as noted above.  The patient is able to ambulate, transfer, toilet and eat with limited assistance.  There is no documentation of recurrent falls.  The assessment does not support the medical necessity for an increase in Personal Assistance Service from 38 to 84 hours per week.  The approved 38 hours per week is sufficient to provide assistance needed with activities of daily living (ADLs) that include meal prep, housework, bathing, dressing, and shopping.

Medically necessary services are those which are:
1) safe. 2) effective. 3) generally accepted national standard of medical practice.  4) not provided primarily for convenience of the patient or the practitioner. 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary because it is not consistent with generally accepted national standard of medical practice for this patient's scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Psoriasis.
Treatment:  Humira.

The insurer denied Humira.  The determination is upheld.

The patient has moderate to severe psoriasis of the ears, feet, and hands. The patient is reported to have tried and failed oral Acitretin (25 milligrams (mg)) by a previous dermatologist. The patient has tried and failed topical 40% urea cream for his thick hyperkeratosis, and also failed topical steroids such as betamethasone dipropionate cream. The patient does not consume significant amounts of alcohol, as per the patient's clinical records.

The medical necessity of Humira is under review.

The patient has insufficient to no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies, such as either Methotrexate, Acitretin, and/or Phototherapy. The documentation of how long and what the treatment response was for this patient's prior Acitretin use does not provide any conclusions that first-line therapies were tried and failed. Therefore, the requested Humira is not medically necessary.

Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Humira, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia (BPH) 
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with benign prostatic hyperplasia (BPH) who was admitted for a transurethral prostatectomy.  The surgery was uncomplicated.  He was treated with continuous bladder irrigation (CBI).  He required intravenous (IV) fluids, IV antibiotics, and IV pain medications.

The patient was discharged home after removal of the catheter.   He was afebrile and hemodynamically stable. 

No, the proposed treatment, inpatient admission, was not medically necessary.

Care after an uncomplicated transurethral resection of the prostate (TURP) can be provided at an observation level of care.  Because there were no signs of complications, infection, excessive bleeding, or instability an acute inpatient level of care was not necessary.  The care of his comorbid conditions was routine.  An observation level of care was appropriate, even with use of continuous bladder irrigation (CBI).