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

Central nervous System
Home health aide

Diagnosis: Dementia.
Treatment: personal care services.
The insurer denied 24 Hour Split Shift - Personal Care Aide (PCA) Services. 
The health plan's determination is upheld. 

24 Hour Split Shift - Personal Care Aide (PCA) Services are not medically necessary. The patient has multiple medical problems including dementia and mobility, diabetes, pulmonary embolism and depression. She is dependent on others with total assistance for almost all activities of daily living.
A letter from the patient's physician states that the physician believes the patient has multiple nighttime changes of soiled diapers and linens as to prevent skin rash and irritation, recommended split shift along with fall prevention.
The recent Uniform Assessment System (UAS) state of New York recommended 58.85 hours a week of care.
The amount of services being provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not indicated. In order for services to be considered medically necessary, the aid must be performing a service such as a medically necessary activities of daily living (ADL) or Instrumental activities of daily living (IADL).
The documentation provided including the UAS, physician notes an appeal letter failed to demonstrate medical need above and beyond a 24-hour live-in aide could provide. In specific, there was no reason noted why a live-in aid could not perform these services. In fact, the patient was allotted 59 hours a week as per UAS which was performed. There is no notation of why the patient would need more than 16 hours a day of care and that the aid could not get proper rest defined as at least 5 hours of interrupted sleep.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missed abortion.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with no past medical history. She presented to the Emergency Room (ER) with complaints of a missed abortion. She was admitted to surgery with a missed abortion. The care plan included obtaining labs, keeping the patient on nothing by mouth (NPO), administering intravenous (IV) fluids, and performing a dilation and curettage (D&C). The patient left the hospital against medical advice (AMA) before the procedure could be performed. 

This patient had a missed abortion necessitating a D&C. D&Cs are ambulatory procedures. D&Cs are done in offices and surgicenters. D&C can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Following a D&C, a patient is usually observed in the recovery room like all patients undergoing an ambulatory procedure and once the provider ascertains that the patient is stable then the patient is sent home. Admission to an acute level of care is not customary or medically necessary. There was no reason submitted why the patient was admitted. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

Based on all the information submitted, the hospital admission was not medically necessary.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with iron deficiency anemia and kidney stones. She was sent to the ED (emergency department) by her PCP (primary care provider) after she was found to have low Hb (hemoglobin) of 6.5 and HCT (hematocrit) of 22.2. She had been prescribed six iron infusions, and she had received three of them. The Hb/HCT (hemoglobin/hematocrit) were checked one week after the last iron infusion. She also reported hematochezia once a month, which she attributed to hemorrhoids. She also complained of shortness of breath on walking one block, and generalized fatigue.

In the ED (emergency department), the patient was hemodynamically stable and afebrile. She was given 1 liter of NS (normal saline), and she was started on IV (intravenous) Protonix, and typed and cross-matched. The patient was admitted to the hospital, and she was given two units of blood.

After the transfusion, the patient's Hb/HCT (hemoglobin/hematocrit) were 8.9/29.5. The GI (gastroenterology) was consulted. The patient underwent EGD (esophagogastroduodenoscopy) and Colonoscopy. The EGD (esophagogastroduodenoscopy) revealed gastric polyps, some of which were biopsied. The Colonoscopy revealed left-sided diverticulosis, small 5 mm (millimeter) polyp in the rectosigmoid colon, and internal hemorrhoids.

The patient was discharged home after the procedures on high fiber diet and outpatient follow up with GI (gastroenterology) and PCP (primary care provider).

No, the Inpatient admission was not medically necessary.

The patient has a long-standing history of IDA (iron deficiency anemia), for which she has been receiving iron infusion. She was sent to the ED (emergency department) by the PCP (primary care provider), as she was found to have low Hb/HCT (hemoglobin/hematocrit). She endorsed one episode of hematochezia per month, which she attributed to hemorrhoids. In the ED (emergency department), she was hemodynamically stable and afebrile. She was found to be profoundly anemic and was admitted for further evaluation and management of her IDA (iron deficiency anemia). She was evaluated by the admitting team and admitted to the hospital for observation. During her hospitalization, she had no episode of hematochezia, and she tolerated diet well. She was given two units of PRBCs (packed red blood cells). Her Hb/HCT (hemoglobin/hematocrit) improved appropriately. She was evaluated by GI (gastroenterology), and she underwent EGD (esophagogastroduodenoscopy) and colonoscopy, and no active bleeding was noted. On EGD (esophagogastroduodenoscopy), she had gastric polyps and no active bleeding. Colonoscopy revealed left-sided diverticulosis, a small polyp, and internal hemorrhoids with no evidence of bleeding. She was discharged in a fair and stable condition. Given this clinical scenario and hospital course, the acute level care was not appropriate, and she could have been safely managed under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia and Coronavirus Disease 2019 (COVID-19).

Treatment: Inpatient admission.

The insurer is denied coverage for the inpatient admission. 

The denial is upheld. 

This is a male patient who has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, immunocompromised status, and generalized anxiety disorder. The patient presented to the hospital for evaluation of shortness of breath and dizziness. He was admitted for further monitoring and management of bronchial asthma in the setting of pneumonia and Coronavirus Disease 2019 (COVID-19) positive status. He was placed on contact and droplet isolation; a repeat COVID-19 test was negative. Pulmonary, Gastroenterology and Psychiatry specialists were consulted. The patient's condition improved, and he was discharged.

Chest X-ray showed some nodules/granuloma, perihilar lesion, and no acute infiltrates. Computed tomography (CT) of the chest was consistent with hamartoma. White blood cell (WBC) count was 14- steroid effect. Influenza screen was negative. A COVID-19 rapid test came back positive but repeat test came back negative. The patient was seen by Pulmonary. The patient was in no acute distress. The patient was afebrile and hemodynamically stable. Their assessment was that the patient had bronchial asthma but not in exacerbation. They recommended switch to oral steroids and that the patient follow-up in an outpatient setting after discharge. 

This patient did not need acute inpatient hospitalization. He was stable to be placed in Observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission. The patient's peak expiratory flow (PEF) was 380. Oxygen (O2) saturations were between 95 to 100 % on room air. Lung examination showed minimal wheeze to clear. The patient was seen by Pulmonary who opined the patient was not in exacerbation and recommended switching to oral steroids. The patient's imaging likely represented hamartoma. The plan was to follow-up in an outpatient setting with positron emission tomography (PET) scan. The patient remained stable after admission and was discharged home after a few days. The patient could have been switched to oral steroids after a period under observation (which could be up to 48 hours). There was no evidence of pneumonia or toxicity. The patient was not hypoxic. The patient was stable for discharge on oral antibiotics with close follow-up in an outpatient setting.  

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a female with history of asthma. She presented to the emergency room with worsening shortness of breath and wheezing. The patient was found to have asthma exacerbation. The patient was admitted for the management of asthma exacerbation.

In the emergency room, the patient received IV (intravenous) steroids, and nebulization treatments with significant improvement. The patient had significant improvement in SOB (shortness of breath)/wheezing. The patient was ambulating and tolerating diet.

The patient's asthma exacerbation was mild. The patient was not on supplemental oxygen. The patient was hemodynamically stable throughout the entire admission. There was no trial and failure of observation level of care for 24 hours prior to admitting patient to acute hospitalization.

No, the Inpatient admission  was not medically necessary.

In the emergency room, the patient received IV (intravenous) steroids, and nebulization treatments with significant improvement. The patient had significant improvement in SOB (shortness of breath)/wheezing. The patient was ambulating and tolerating diet.

The patient's asthma exacerbation was mild. The patient was not on supplemental oxygen. The patient was hemodynamically stable throughout the entire admission. There was no trial and failure of a lower level of care prior to admitting patient to acute hospitalization.

The patient's inpatient admission for asthma exacerbation was not medically necessary. The patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis/Abscess.

Treatment: Inpatient level of care.

The insurer denied coverage for inpatient level of care.

The denial is upheld.

The patient is a male patient with a history of methicillin-resistant Staphylococcus aureus. The reason stated by the Emergency Department physician for admission is that the patient "failed outpatient management, worsening of infection despite oral antibiotics." Soft tissue infection of left thigh area had improved on clindamycin given for last 2 days, but similar infection on the right became bigger and painful, with an area of redness that had spread beyond where mother had drawn a line with a marker. He had fever 102.5 at home, but was eating and drinking normally. The patient also had history of recurrent ear infections. 

On exam, he was described as well-appearing, non-toxic, with bilateral red bulging tympanic membranes, with a 1 centimeter diameter furuncle on his left thigh, and a 3 centimeters erythematous and warm area on his right thigh with induration and a small central fluctuant area (1 centimeter) with crusted over previously draining tract, with mild erythema and warmth between this area and his genitals. He was moving extremities normally. 

Note that the area of fluctuance was not 3 centimeters on the emergency department physician exam, as is stated in the appeal document above. The white blood cell count was upper end normal for children at 14,900 with appropriate 71% neutrophilic response on the differential count. 

Bedside incision and drainage was performed by Surgery in the emergency department, with an unspecified but apparently small amount of pus drained, and no drain was inserted. The definitive treatment of his abscess, which was less than 5 centimeters in diameter, was incision and drainage, and parenteral antibiotics were unnecessary because he did not present with any signs of sepsis and the likelihood of bacteremia was extremely small. This scenario is specifically addressed in reference number 1. His lack of improvement was not a failure of outpatient antibiotic therapy, rather a change of antibiotic empirically was indicated after incision and drainage attempt. It would have been appropriate to perform cultures from the drainage, begin empiric antibiotics and adjust the antibiotic therapy as an outpatient.  

The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The administration of vancomycin and ceftriaxone was unnecessarily overly broad coverage in a toddler not suspected of having sepsis, myositis, or fasciitis. 

The insurer's denial of coverage for the inpatient level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intractable back pain.

Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.

The denial is overturned. 

This is a male patient with no significant past medical history who presented to the Emergency Department (ED) with intractable back pain. The patient also endorsed difficult ambulation and neck stiffness. In the ED, the patient received multiple pain medications including morphine without significant relief. The patient was unable to ambulate or sit up in the ED. Magnetic Resonance Imaging (MRI) of the lumbar spine was performed and the impression was: No acute fracture; no compression of the conus or cauda equine; annular bulge at L5-S1; transitional lumbosacral vertebra with lumbarization of S1; pseudoarthrosis of the transverse processes of the transitional vertebra with a sacral ala with bone marrow edema. It was noted that in the proper clinical setting, these findings could represent the initial presentation of Bertolotti syndrome. The patient was admitted to inpatient care for severe diffuse lower back pain bilaterally due to muscle spasm that resulted in the patient's inability to ambulate. Pain management was consulted and performed lumbar trigger point injection in the right lumbar paraspinal region, erector spinae and quadratus lumborum. The patient's pain improved but he experienced mild soreness in the lower back due to the injection. The patient was eventually able to ambulate on his own and was discharged with recommendations for outpatient Physical Therapy.

The patient was unable to sit up or ambulate. He was unable to perform his activities of daily living (ADLs) and received opiate medications for pain. These two factors are explicitly mentioned in the Milliman Care Guidelines (MCG) 24th Edition: Back Pain as criteria for admission.

Further, Joint Commission standards (2) require:
"The hospital reassesses and responds to the patient's pain though the following: ...
Progress toward pain management goals including functional ability (for example, ability to take a deep breath, turn in bed, walk with improved pain control."

The admission was required by the standard of care and was medically reasonable and necessary.

The healthcare plan did not act with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorder/Other (Sarcoidosis).
Treatment: Pharmacy/Prescription Drugs (Humira) .
The health plan denied the requested prescription drug as not medically necessary. 
The health plan's determination is upheld.

The patient is a man with a history of pulmonary sarcoidosis and possible erythema nodosum, who has been on moderate to high intermittent doses of tapering steroids for 60% of the time. A computed tomography (CT) of the chest showed mediastinal and hilar lymphadenopathy and bilateral upper lobe subpleural fibrosis and honeycombing. Humira was recommended by the treating physician as a steroid sparing therapy. The prior authorization was denied as a trial of other steroid sparing agents like Methotrexate, Leflunomide, Azathioprine and Cellcept were recommended as first line. The provider appealed the decision stating the patient has mildly elevated liver function test and drinks 2 shots of liquor a week or 2 ounces total a week that prohibits the use of Methotrexate, Leflunomide and Azathioprine. The appeal was again denied stating the alternative first line steroid sparing therapies can still be tried.
At issue is the medical necessity of the requested prescription medication, Humira.

I uphold the health plan's determination of denying coverage of Humira at the moment.

The request for Humira for the treatment of pulmonary sarcoidosis is not at the moment medically necessary. As anti-tumor necrosis factor (TNF) therapy is considered second line steroid sparing therapy after first line steroid sparing therapies like Methotrexate, Leflunomide, Azathioprine or Cellcept are tried. Mild alcohol and mild liver function abnormality does not completely bypass the need to try first line of steroid sparing agents.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Ventolin HFA. 

The insurer denied Ventolin HFA.  The denial is upheld.

The patient is a male with a history of asthma who is requesting coverage for brand name Ventolin HFA (albuterol). In an appeal letter, his provider stated that the patient's asthma was well controlled on brand name Ventolin, but, according to the patient, a recently tried generic form of the medication was ineffective. There are no medical records further documenting the aforementioned clinically ineffective trial, or other previous ineffective trials.

The health plan's determination is upheld.

Besides the brand name Ventolin HFA, there are six other generic metered dose albuterol inhalers on the market that are approved by the Food and Drug Administration (FDA). To gain FDA approval for a generic product, the manufacturer needs to demonstrate that their product must perform the same in the body as the brand name, meet the same high standards of quality in manufacturing, and use the same active ingredients. The patient's pharmacy plan requires evidence of failure of at least two of the preferred agents. In this case, there is relatively weak evidence (the patient's report documented in an appeal letter) that he failed only one trial of generic albuterol. Therefore, based on the standard of care, as well as the peer reviewed literature, FDA's recommendations, the numerous generic options, it cannot be demonstrated the formulary drugs would not be effective for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Inpatient. (Custodial Care Services)
The insurer denied Custodial Care Services. 
The denial is upheld.  

The patient is a male with past medical history of alcohol abuse, and marijuana abuse admitted to hospital with frostbite, gangrene of bilateral feet status/post (s/p) right trans metatarsal amputation (TMA) on and s/p amputation of left 1st, 2nd, 3rd, 4th, 5th toes. The patient was treated with intravenous (IV) antibiotics. Pathology findings were consistent with (c/w) osteomyelitis. Documentation noted that he was discharged to complete 4 more weeks of IV antibiotics. Then it was noted that Nursing Home coverage was requested and denied. The subject under review is the medical necessity for custodial care for this patient.

The health plan's determination is upheld in whole.

Custodial care services are not medically necessary for this patient.
The patient is a male s/p right TMA  and s/p amputation of left 1st, 2nd, 3rd, 4th, 5th toes. Despite these amputations therapy noted that the patient was ambulating 15' with supervision. Also Wound Physicians noted that while the patient had moderate serous exudate from post-surgical right foot wound requiring debridement during visits the dressing treatment, at most, was daily. Additionally a Comprehensive Community Health Assessment Report noted that patient was independent with daily decision making and patient was able to recall what was learned or known supporting that he could provide himself daily dressing changes. The Mood/Behavior section of the report also noted that "No mood or behavioral issues observed or reported" supporting that the patient did not have a behavioral component that would preclude living in the community. It also noted that the patient was independent with meal preparation, managing finances, bathing, personal hygiene, upper and lower body dressing, walking, toilet use, bed mobility, toilet transfer and eating and only required "Help on some occasions" for ordinary housework. Therefore, custodial care was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholangitis, Acute Cholecystitis or Calculous

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission

The denial is upheld


The patient is a female with a history of cholecystectomy. The patient presented with flank pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The liver enzymes were elevated. An abdominal ultrasound revealed a dilated common bile duct. This was felt to be related to a previous cholecystectomy. There was a concern that she had a common bile duct stone.  Steroids were given prior to an endoscopic retrograde cholangiopancreatography. Hepatitis viral serology was negative. An endoscopic retrograde cholangiopancreatography with sphincterotomy was done. The bile duct was clear. It was felt that she passed a small stone spontaneously.

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) include having acute cholangitis, acute cholecystitis or calculous causing a complication. This complication could be hemodynamic instability, severe vomiting, severe dehydration, severe pain, bacteremia, or an obstructed bile duct. The patient did not have these conditions.

This patient passed a small stone through her common bile duct. She did not have acute cholecystitis, acute cholangitis or systemic signs of inflammation. She required an endoscopic retrograde cholangiopancreatography but it could have been done without the need for an acute care inpatient hospitalization. 

The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.