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

Diagnosis: Cirrhosis.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a female patient with a medical history of cirrhosis complicated by portal hypertension, ascites, splenomegaly, and esophageal varices; Lyme disease; sleeve gastrectomy; and anxiety. She presented to the hospital for evaluation of portal hypertension. Vital signs were notable for an elevated blood pressure of 144/100 mmHg (millimeters of mercury). The physical examination was notable for a soft, nontender, nondistended abdomen with normal active bowel sounds. Lab results showed a low platelet count of 89 thousand per microliter (K/uL), low potassium of 3.4, elevated aspartate aminotransferase of 60, and elevated bilirubin of 2.0 milligrams per deciliter (mg/dL). She was made nil per os. She underwent angiography of the hepatic artery (which showed an unremarkable celiac artery and portal veins patent with hepatoportal flow) and transvenous liver biopsy. She underwent a diagnostic paracentesis. She was discharged. At issue is the medical necessity of the inpatient level of care.

The inpatient level of care was not medically necessary, and the care provided during the brief stay could have been provided at a lower level of care. The patient presented for evaluation of portal hypertension in the setting of cirrhosis [1]. A large-volume paracentesis can result in circulatory or renal dysfunction, but the patient only underwent a diagnostic paracentesis, without the risk for hemodynamic or renal decompensation [2-6]. She underwent evaluation for trans jugular intrahepatic shunt (TIPS) placement with hepatic angiogram, but the TIPS was not placed. There was no hemodynamic instability, ascending cholangitis, acute liver failure, or other complications which would require the inpatient level of care [7-9]. For these reasons, the care provided during the day at issue could have been provided at a lower level of care, without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Pancreatic cancer

Treatment: Level 2 personal care services, per 15 minutes increase to 76 hours per week

The insurer denied coverage for Level 2 personal care services, per 15 minutes increase to 76 hours per week

The denial is modified

 
This is a patient recently diagnosed with pancreatic cancer and has scheduled chemotherapy treatments.  She lives alone in a private residence.  The insurer approved personal care services (PCS) level 2; 42 hours/week and the request is for PCS level 2; per 15 minutes increase to 76 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognition is modified independent.  She is reportedly totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She reportedly requires maximal assistance for bathing, lower body dressing, and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation.  However, she was observed "walking with an unsteady gait and a cane in doors."  She is independent for eating and bed mobility.  The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.   Her activity of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  She has also fallen on multiple occasions over the past 90 days.  However, the patient's functional ability is described as much the same when compared to the prior UAS report. 

Based on the enclosed documents, the patient's clinical and functional deficits are not at a level and unpredictable as to require the requested PCS 76 hours/week.  Given the patient's reported diagnosis, anticipated treatment and progressive general weakness/debility, she may benefit from additional safety monitoring.  Safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   However, the patient's current condition, level of debility and likely progression does support increasing PCS to 60 hours/week.  Based on the records reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCS level 2; 60 hours/week.   This physician also recommends reassessment in approximately 90 days, given the likely progression of her clinical condition and functional impairment.  

Based on the above, the insurer's denial must be modified. 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 Level 2 personal care services, per 15 minutes increase to 76 hours per week is not substantiated. However, increasing PCS level 2; per 15 minutes increase to 60 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic heart disease, diabetes, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, hearing loss, history of femur fracture, and osteoarthritis

Treatment: 24 hours per day - split shift - personal care aide (PCA) services.

The insurer denied coverage for 24 hours per day - split shift - personal care aide (PCA) services.

The denial is overturned.

 
This is an elderly patient with chronic heart disease, diabetes, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, hearing loss, history of femur fracture, and osteoarthritis. She lost her balance and fell resulting in a femur fracture. She has ongoing pain. She has spent time in a nursing home setting. She is total assist for household chores and meal preparation. The patient requires extensive assistance with managing finances, managing medications, phone use, personal hygiene, upper body dressing, walking, and toilet transfers. She requires care at night for transfers, and incontinence care.  Logs show assistance provided 10-12 times per night between 7pm and 6am. Longest stretch without care is 2hours and 45 minutes.

The plan approved 24 hour "live-in" personal care services at 91 hours per week. The need for further care would be addressed in six months. The requested 24 hour is split shift for a total of 168 hours per week. Because of her ongoing care needs, it is unlikely for one caregiver to obtain the required five hours of uninterrupted sleep. Therefore, split shift care was requested.

This request is supported. Given the night time needs, it is not feasible for a single live in to provide the needed services and still obtain the needed amount of uninterrupted sleep 

Based on the above, the insurer's denial must be overturned. 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 24 hours per day - split shift - personal care aide (PCA) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The insurer has denied coverage for a hospital admission. In their Final Adverse Determination letter, they write that the patient came to the hospital for a kidney stone. The plan clinical criteria consider a full hospital admission for kidney stones medically necessary when severe problems exist. These might include a single kidney blockage, uncontrolled blood pressure, or blockage in both kidneys. The information provided does not show the patient had these or any severe problems. The inpatient admission did not meet the MCG (Milliman Care Guidelines) guideline Renal Colic and Kidney Stones, Pediatric. 

The hospital is appealing. In an appeal letter, the hospital writes that there was noted concern over severe abdominal pain with inability to rule out appendicitis, and ureteral calculus, with urinary obstruction and hydronephrosis. The documentation in the medical record validates the acuity of illness thereby supporting the designated level of care. 

This is a patient who presented to the emergency department with complaints of right lower quadrant (RLQ) abdominal pain associated with nausea/emesis. The patient initially presented to urgent care where the patient was given laxatives and an enema with moderate relief of symptoms.  However, pain returned a few hours later so the patient presented to emergency department. Computed tomography (CT) scan revealed a 2 millimeter (mm) in right ureterovesical junction (UVJ) area with mild right pelvocaliectasis. The patient given intravenous (IV) fluid bolus in emergency room, oral Flomax, intravenous Toradol, Zofran. The patient seen by general surgery and appendicitis was excluded, urine strained and revealed some sediment. The patient was deemed stable for discharge on 3/20/23; the patient's pain improved significantly after a large bowel movement. The insurer has denied coverage for the hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (26th) renal colic and Kidney stones- pediatric, patient fails to meet guidelines for admission. These include hemodynamic instability, bilateral obstruction, acute renal failure of stage 2 acute kidney injury (AKI) or obstruction of patient's only functioning kidney. The patient had no urinary tract infection and no obstruction of a renal transplant. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity and Hypothyroidism. 
Treatment: Wegovy 0.5 mg (milligrams) Pen Injector. 
The insurer denied Wegovy 0.5 mg Pen Injector. 
The denial is upheld. 

This is an adult female with hypothyroidism and obesity with a body mass index of 40.41 kilograms per meter squared (kg/m2) with obstructive sleep apnea, polycystic ovarian syndrome, and a history of gestational diabetes. She is currently in Weight Watchers program and a comprehensive medical weight loss program. Request for Wegovy is under review. The prior request was denied due to supply issues, as gradual increase to the 2.4 milligram (mg) target dose cannot be reliably and safely completed. The provider is appealing this determination as the patient can still obtain the medication. 

The requested Wegovy is not medically necessary. 

This request is for Wegovy for the treatment of obesity. The prior request was denied due to supply issues, as gradual increase to the 2.4 milligram target dose cannot be reliably and safely completed. The Novo Nordisk website [1] confirms that many patients will have difficulty filling quantities of 0.25 milligrams, 0.5 milligrams, and 1 milligram dose strengths. Without each of these dose strengths, this patient will be unable to titrate Wegovy in a manner consistent with the Wegovy prescribing information. Therefore, the requested Wegovy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rotator Cuff Tear, Acromial Stress Fracture. 
Treatment: Acromial Fracture Fragment Excision. 
The insurer denied the acromial fracture fragment excision. 
The health plan's determination is upheld. 

The patient is a male patient with a complaint of right shoulder pain. An index rotator cuff repair was performed. Due to persistent pain, a follow up magnetic resonance imaging (MRI) scan of the right shoulder was obtained and confirmed a recurrent full thickness rotator cuff tear with superior migration of the humeral head and arthritic changes present. The tears were retracted 3 centimeters (cm) and there was atrophy present as well. 
The patient experienced an increase in pain in this shoulder and had a second MRI scan of the right shoulder done. This study confirmed an acromial stress fracture in addition to the previous findings of a massive, retracted rotator cuff tear. A computed tomography (CT) scan of the right shoulder confirmed advanced glenohumeral osteoarthritis and a persistent acromial fracture. The patient opted to undergo elective excision of this persistent anterior acromial fracture fragment. 

The requested health service/treatment of shoulder surgery for partial acromionectomy was not medically necessary for this patient. The medical records document that this patient suffered from a recurrent massive rotator cuff tear as well as right shoulder arthritis consistent with rotator cuff arthropathy. The progress notes detail that the treating orthopedic surgeon entertained the possibility of performing superior capsular reconstruction to remedy this patient's pain. The treatment plan then switched to treatment of an anterior acromial fracture non-union. The notes, however, do not detail how the acromial fracture became the primary source of this patient's right shoulder pain, nor do they explain how the excision surgery would remedy the pain from this patient's massive recurrent rotator cuff tear or his underlying shoulder arthritis. Thus, the medical necessity of this surgery is not established in this case. 
In addition, there is no support for excision of a traumatic acromial fracture fragment in the peer-reviewed literature. There is a case report of open reduction and internal fixation as reported by Yu and colleagues in 2021 and a report of clinical examples as reported by Hess and associates in 2019. These articles, however, do not support acromial excision surgery. Therefore, the treatment in this case is not supported by the peer-reviewed literature and the medical necessity of the surgery performed is not established. 

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of falls, hypertension (HTN), dizziness, Diabetes mellitus (DM), and peripheral vascular disease (PVD)

Treatment: 21 hours/week; consumer direct; 1 client personal care aide (PCA)

The insurer denied coverage for 21 hours/week; consumer direct; 1 client personal care aide (PCA)

The denial is upheld.

 
According to the medical records, the patient has a history of falls, hypertension (HTN), dizziness, Diabetes mellitus (DM), and peripheral vascular disease (PVD). The request is for 21 hours/week; consumer direct; 1 client personal care aide (PCA), which is under review.

There is no medical change or reason for the increase in hours needed. The patient may have some safety needs in the home or in general, but this is not within the scope of an Aide.      

The patient is already receiving PCA hours. The patient can wash, dress, and eat for self. The current hours for assistance are adequate for the patient's personal care and daily task needs. There was no other information provided or change in medical condition to warrant an increase in PCA hours.

"Home care (HC) workers provide essential health and personal care supportive services that enable people to live at home rather than receive care in a nursing home or other facility. The great majority of those who receive HC are people over age 65 years, as well as those of all ages with illness or disabilities." (Quinn, M. M. et al. 2021).

"While family caregivers have traditionally provided care for older adults with chronic conditions and disabilities, the demand for paid home care workers has increased in the last decade. Although typically thought to assist with personal care, emerging data suggest that paid home care workers assist with a wider scope of care. However, the extent and quality of the care they deliver remains poorly understood." (Sterling, M. R. et al. 2022).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 21 hours/week; consumer direct; 1 client personal care aide (PCA) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult male was hospitalized for chest pain. He was transferred by ambulance from an outside hospital to the emergency department for evaluation of severe chest pain which awoke him at 4:00 a.m. Treatment included an ST elevation myocardial infarction (STEMI) alert and intravenous heparin infusion. The patient's past medical history is pertinent for his brother who had a myocardial infarct (MI) and multiple coronary stents. The patient's vital signs were stable. Electrocardiogram (EKG) showed SR and ST segment elevation in the septal leads associated with inferior ST depression. Labs revealed transaminitis. Imaging was conducted including coronary computed tomography angiography (CTA) which showed multifocal plaque. Hepatobiliary iminodiacetic acid (HIDA) scan was remarkable for retention of activity suggestive of underlying hepatic dysfunction. Intravenous heparin was discontinued, and the patient was cleared for discharge on day #3 with recommendations including continuing aspirin, Lipitor and follow-up with his primary care physician (PCP) for trending of his liver function tests (LFTs). This is an appeal of the denied claim for the requested acute inpatient hospital stay for this patient.

The proposed inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay, because the severity of this patient's illness did not meet the 
intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines (MCG) criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including treatment for possible ST elevation myocardial infarction, which turned out to be from probable gallbladder disease (GBD) like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is a teenaged male. He had abdominal pain and was found to have constipation. He was hospitalized.

Brief summary of hospital stay:
Emergency department note - the patient was seen in emergency department for abdominal pain. X-ray showed stools in the large bowel.  The Plan was to admit.  Surgery consult reflects no acute surgical issues, consistent with constipation.  Miralax was recommended.
The patient was admitted for constipation; the Plan was for monitoring.  The patient had adequate oral intake (PO) and there was no need for intravenous fluids (IVF).  The patient was to continue Miralax and regular diet.  The patient was doing well and was discharged home late evening.

The proposed treatment was not medically necessary.

Constipation is the most common problem in children. The management usually involves outpatient treatments including dietary modification and different laxatives. For patients with severe constipation and fecal impaction not responding to oral medications, inpatient care with nasogastric (NG)-tube bowel clean-out may be indicated (1-2).

As documented in clinical notes, this patient had abdominal pain and was found to have some stools in the colon. There were no surgical issues such as bowel obstruction. The plan was to send the patient home from the emergency department (ED) but then was to admit him for monitoring. The patient stayed in the hospital for one day and did not require bowel cleanout by nasogastric tube. The patient took Miralax orally and was on a regular diet. There was no documentation for any other acute medical issues. Thus, the proposed treatment was not medically necessary. The requested inpatient monitoring could have been achieved at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that the patient asked to be admitted to the hospital for care because of a health problem. The patient had a fever and was not unstable. To approve this admission, certain criteria have to be met. These criteria are from the guideline named "Sepsis and Other Febrile Illness, without Focal Infection." The medical necessity for paying for the hospital stay at the "Inpatient" level of care has not been established. They have approved the hospital stay at an "Observation" level of care. 

The hospital is appealing. In an appeal letter, the nurse writes that this patient presented to the Emergency Department (ED) with left flank pain and evidence of sepsis (tachycardia, fever, leukocytosis) in addition to anemia on labs, an abnormal urinalysis, poor oral intake, pneumonia on chest x-ray, and pyelonephritis on computed tomography (CT) scan. This patient has a history of sickle cell disease and prior pyelonephritis. The patient was admitted for further treatment with a clinical impression of severe sepsis due to pyelonephritis and pneumonia. Acute inpatient admission was medically necessary and appropriate in this case. 

The patient was admitted with worsening flank pain and was found to have pyelonephritis. The patient was treated with intravenous (IV) fluid and antibiotics. The patient tolerated treatment well and their condition responded adequately. The patient was discharged in stable condition. 
 
The patient was admitted for urinary tract infection (UTI). During this hospital stay, the patient remained hemodynamically stable and responded appropriately to antibiotic therapy. The medical records did not note that the patient had persistent infection, severely abnormal vital signs or severe sepsis which required inpatient level of care. 

Patients with an uncomplicated UTI (e.g., no fever, no flank pain) are treated as outpatients (if no other indication for admission is present) (1,2).  Some patients with an uncomplicated upper UTI (e.g., hemodynamically stable, able to maintain hydration orally) do not require inpatient admission (3).  Database analysis including 572,479 adult visits to an emergency department for UTI found an inpatient admission rate of 17 (4). Another analysis of a national database found that out of more than 1.5 million visits to the emergency department for pyelonephritis, 27% (percent) were admitted to inpatient care (5). 

Therefore, per standard of care and evidence-based literature, inpatient admission was not medically necessary and lower level of care was more appropriate. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.