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

Diagnosis: Dementia, Urinary Incontinence, Falls.

Treatment: increase in Personal Care Services, per 15 minutes/Consumer Directed Personal Assistance Services (CDPAS) from 56 hours to 70 hours per week.

The insurer denied coverage for an increase in Personal Care Services, per 15 minutes/Consumer Directed Personal Assistance Services (CDPAS) from 56 hours to 70 hours per week.

The denial is overturned.

The patient is an older adult with a history of dementia, urinary incontinence, diabetes, and falls. 
There is a letter from the patient's provider that states for the past few months the patient got worse, hardly walks with a walker and assistance, wanders on the streets, gets lost, was found a few times in the police department or emergency room and had a few episodes of falling. The patient is reported to have speech and memory problems including forgetting their name and location and is reported to have no ability to activate emergency assistance. The patient is reported to require an assistant around the clock. The request is for an increase in Personal Care Services, per 15 minutes/Consumer Directed Personal Assistance Services (CDPAS) from 56 hours to 70 hours per week.

An increase in Personal Care Services, per 15 minutes/Consumer Directed Personal Assistance Services (CDPAS) from 56 hours to 70 hours per week is medically necessary, as the patient's safety is of concern given the patient's recent falls, incontinence, cognition, wandering and ambulatory issues. The patient has been found wandering outside of the home and has ended up in the emergency room and in the police department, all of which pose a medical risk to the patient. The recent Nursing Facility Level of Care (NFLOC) provides objective documentation of worsening conditions.

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

The medical necessity for an increase in Personal Care Services, per 15 minutes/Consumer Directed Personal Assistance Services (CDPAS) from 56 hours to 70 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult female patient was hospitalized for abdominal pain and vomiting. Her past medical history is remarkable for hyperlipidemia, asthma, anxiety, and hiatal hernia. The patient's vitals were stable, and temperature was 100.6. Computed tomography (CT) of the abdomen and pelvis was negative. There was non-diagnostic elevation of troponin and electrocardiogram (EKG) was remarkable for no acute changes, left axis deviation, and poor R-wave progression. Urinalysis revealed bacteriuria, and she was treated with Cipro and referred for outpatient management. The issue under review is inpatient hospital admission.

The requested health service was not medically necessary.

Based on the current peer-reviewed medical literature, criteria for inpatient admission were not met, including hemodynamic instability; acute abdomen like small bowel obstruction (SBO) 
requiring surgery; vomiting due to significant metabolic derangement (e.g., severe hypercalcemia, diabetic ketoacidosis); other cause of vomiting requiring hospitalization (e.g., poisoning, increased intracranial pressure, migraine with status migrainosus); vomiting that is severe or persistent; or severe electrolyte abnormalities requiring inpatient care. Inpatient 
admission criteria also include severe pain requiring acute inpatient management; acute myocardial infarction (AMI) or elevated troponin not explained by infection; sepsis bacteremia; appropriate outpatient antimicrobial treatment unavailable, not effective, or not feasible; acute kidney injury (stage 2); acute renal failure (stage 3 acute kidney injury); inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists despite observation care; or parenteral nutrition regimen that must be implemented on inpatient basis. Therefore, based on the information submitted and the current standard of care guidelines, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Trauma/Injuries
Physical Therapy

Diagnosis: traumatic brain injury (TBI)
Treatment: physical therapy
The insurer denied physical therapy
The health plan's determination is overturned. 

The patient is a young female with history of brain injury and paralysis with autonomic dysreflexia, neurogenic bladder and chronic lung disease due to motor vehicle accident (MVA).

The requested physical therapy (locomotion training) is medically necessary for this patient. The patient has documented tetraplegia and traumatic brain injury (TBI), with autonomic dysreflexia, chronic lung disease and bladder and bowel dysfunction. The requested physical therapy and plan for locomotion training is current standard of care and well documented in the literature as working to improve overall motor function as well as health status in children with gait dysfunction, spinal cord injury (SCI), and TBI, improving respiratory status, bladder and bowel function, bone density, endurance and overall quality of life.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental disorder
Treatment: Braces, retainer, and monthly visits
The insurer denied the braces, retainer, and monthly visits.
The determination is overturned.

The patient is a female. She presents with a skeletal Class III malocclusion. She has maxillary and mandibular spacing. Teeth 7 and 10 are in anterior crossbite. She is treatment planned for 30-36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces, retainer, and monthly visits.

Teeth 7 and 10 are at high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Further movement of teeth 22 or 27 will likely lead to the need for future for periodontal grafting on these teeth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: right gluteal pain and swelling. 

Treatment: inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is an adult with a past medical history significant for hypertension, diabetes mellitus, and hyperlipidemia. The patient presented to the emergency room (ER) with complaints of right gluteal pain and swelling. 

Vital signs on presentation included: Temperature of 101.5 degrees Fahrenheit, Blood Pressure 108/60 mmHg, pulse 89 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation of 98% (percent) on room air. Laboratory values were notable for the following: white blood cell (WBC) count 15.69, hemoglobin (Hgb) 11.7, hematocrit (Hct) 35.4, creatinine 1.02, glucose 292, and lactate 2.2. 

The patient was empirically started on intravenous antibiotics. A computed tomography (CT) scan of abdomen/pelvis showed a large right perianal abscess. General surgery was consulted. The patient underwent a bedside incision and drainage (I&D) procedure. After the procedure, the patient was tachycardic requiring an intravenous (IV) fluid bolus. Preliminary blood culture grew bacillus species. The patient signed out of the hospital against medical advice (AMA). 

According to documentation, the patient presented with a right gluteal abscess. The patient was febrile and laboratory results showed multiple abnormalities including elevated white blood cell (WBC) count, glucose and lactate. A computed tomography (CT) scan confirmed a large perianal abscess that required surgical intervention. Based on the above findings, the hospital admission was medically necessary for administration of intravenous antibiotics and surgical intervention. 

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Neck Injury. 
Treatment: Air ambulance services (procedure code A04730). 
The insurer denied coverage for air ambulance services (procedure code A04730). 
The denial is overturned. 

According to the patient's medical record summary this is a young adult who suffered a cervical (C) 5 dislocation with neurologic findings. The patient was transferred for definitive surgery from outside the United States to a hospital within the United States for definitive surgery the same day. As per the history and physical (H & P) this patient jumped from the roof of a shallow boat and landed on their head with an audible crack in the neck. The patient felt sudden numbness in bilateral hands and ulnar side of the hands. A computed tomography (CT) of the spine at showed a C 5-6 dislocation. 

The patient was transferred via air ambulance and underwent C5-6 anterior cervical discectomy, bilateral foraminotomies and placement of anterior structural allograft and Atlantis plate with inferior screws. Postoperatively the patient received occupational therapy (OT) and physical therapy (PT) and continued to do well. 

Medical guidelines for airline passengers from the aerospace medical association were reviewed. 

Based upon the records provided and guidelines from the insurer as well as the clinical information provided and applicable practice guidelines, the transfer by air ambulance was medically necessary as the patient could not receive the appropriate care from providers in a timely fashion. They initially were going to stay at the outside hospital-however when it was noted that it was going to be delayed after being told it would be done, they decided to transfer the patient. This was in the setting of the trauma surgeon telling them that it should be done as soon as possible (ASAP). Therefore, it was not to bring the patient closer to home that the transfer was done-it was being done to expedite the care after the family had lost faith in the hospital being able to care for the patient. 

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

The medical necessity for air ambulance services (procedure code A04730) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is an adult male with a diagnosis of acute appendicitis. The patient was seen in the emergency department with complaints of abdominal pain. Labs showed a creatinine of 1.6 and white blood cell count of 10. The patient had abdominal tenderness but no rebound or guarding. A computed tomography (CT) scan showed appendicolith and acute appendicitis. The patient was taken to the operating room, underwent laparoscopic appendectomy, and was discharged home. There was no hemodynamic instability at any points. The request is to review for inpatient admission.

The requested health service was not medically necessary.

Inpatient admission was not medically necessary in this case as the patient had uncomplicated appendicitis. The patient was discharged home right after surgery. The patient was hemodynamically stable all throughout his stay and his white blood cell count was 10. There was no evidence of complications or medical issues that needed continued medical observation or workup. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Burns
Treatment: Inpatient Hospital Stay

The insurer denied the inpatient hospital stay.
The determination is upheld.

This patient is a female who presented to the hospital with 37.5 percent (%) total body surface area mixed second and third-degree burns of the head, neck, chest, back, bilateral upper extremities, and bilateral feet following a propane tank explosion in her trailer. She was admitted to the hospital and treated for burns, facial fractures, multiple left rib fractures, and pneumothorax. After undergoing multiple surgical procedures, the patient was discharged and sent to a medical rehabilitation unit. The patient required an inpatient level of care for the placement of a percutaneous endoscopic gastrostomy tube (PEG) and to undergo open reduction internal fixation for a right zygomatic arch fracture and right orbital wall fracture. The patient underwent PEG placement and open reduction internal fixation (ORIF) of the zygoma and right orbital wall fractures. The patient's management involved multimodal oral medications, and arrangements were made for enteral feedings and medications via the PEG tube. The patient was discharged from the inpatient setting. At issue is the medical necessity of continued inpatient stay.

Question(s):
Acute inpatient admission was not medically necessary for this patient. While this patient was critically injured and required a prolonged inpatient admission, the coordinated care of multiple medical services and multiple surgical procedures to treat her numerous injuries helped stabilize her condition, and she then received treatment in a medical rehabilitation unit.

After being treated in a medical rehabilitation unit, the patient was transferred to an inpatient level of care. She underwent a percutaneous endoscopic gastrostomy tube placement along with an open reduction internal fixation of a right zygomatic arch fracture and right orbital wall fracture. Patient management involved multimodal oral medications, and arrangements were made for enteral feedings and medications via the PEG tube. The patient was discharged from the inpatient setting. 

The patient was clinically and hemodynamically stable. She had normal vital signs. The patient did not have complications related to the procedures. The care and treatment provided did not mandate an inpatient level of care, as this treatment could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: diarrhea and vomiting

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult who presented via ambulance to the emergency room (ER) with a history of 1 day of non-bloody watery diarrhea and an episode of vomiting which was associated with right upper quadrant/epigastric abdominal pain. Imaging showed no evidence of cholelithiasis or biliary ductal dilatation. X-ray showed no acute infiltrate seen. Computed tomography (CT) of the abdomen and pelvis revealed that the cecum and proximal ascending colon were thickened and edematous, consistent with an acute segmental colitis. The patient was admitted for colitis with bandemia, and viral gastroenteritis.

The patient continued to have diarrhea and right sided abdominal pain on day 1 of the admission. He denied nausea/vomiting/fevers/chills. Intravenous Cipro and Flagyl was continued with intravenous fluids. 

On day 2, the patient reported no events overnight. He remained afebrile and stable. He endorsed mid improvement in abdominal pain, had some cramping with liquid intake. He still had watery diarrhea but also improved. He was switched to oral cipro and a probiotic. Diet was advanced to soft.

According to the Milliman Care Guidelines, Admission is indicated for 1 or more of the following: Suspected severe infection (e.g., fever with bloody diarrhea), Severe abdominal pain, Peritoneal signs, Toxic megacolon, Hemodynamic instability, Vomiting that is severe or persistent, Dehydration that is severe or persistent, Severe electrolyte abnormalities requiring inpatient care, Hemolytic uremic syndrome, Inability to maintain oral hydration (e.g., needs intravenous (IV) fluid support) that persists after observation care.

The presenting symptoms of the patient does not require inpatient admission based on the indication by the Milliman Care Guidelines. The complaints and the treatment and procedures rendered can be given in a lower level of care such as outpatient care in emergency department, rapid treatment site, urgent care center, or medical office. 

According to the referenced literature, most patients who present to outpatient clinics or the emergency department with acute viral gastroenteritis can be discharged home safely. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right sided numbness.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns for right sided numbness and tingling. Pertinent history included polycythemia, unspecified and hyperlipidemia. Initial vital signs revealed a temperature of 98.4F, heart rate (HR) 70, blood pressure (BP) 148/82, respiratory rate (RR) 18, and oxygen saturation 100% (percent) on room air. Initial examination documented the patient as alert and oriented with a National Institute of Health Stroke Scale (NIHSS) of 0. Laboratory testing relatively was unremarkable. An electrocardiogram (EKG) showed sinus rhythm without acute ischemic changes. Chest radiograph was unremarkable. A computed tomography (CT) Head was unremarkable. CT brain perfusion was unremarkable. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient presented with concerns of right-sided numbness and tingling. Initial examination documented an NIHSS of 0. An extensive evaluation was performed including an electrocardiogram, laboratory testing, and multiple CT imaging modalities which was unremarkable for an acute pathological process. Antiplatelet medication was provided, but tPA not deemed necessary. Neurology consulted and recommended additional diagnostic testing. Following observation care, presenting symptoms had completely resolved and the patient left the hospital prior to obtaining an magnetic resonance (MR) brain. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is an adult female with no significant past medical history who presented to the emergency room for elevated liver function tests (LFTs). She presented recently for abdominal pain and nausea and was called back for elevated liver function tests. 
On admission, the patient was noted to have a heart rate of 104 and potassium of 3.3. Her alkaline phosphatase level was 133, aspartate aminotransferase (AST) was 459, and alanine aminotransferase (ALT) was 567. Her hepatitis A antibody was positive. An ultrasound of the gallbladder showed cholelithiasis. 
The patient was admitted with intravenous fluids, gastrointestinal consult, and plan to repeat liver function tests. General surgery and gastroenterology were consulted. The patient tested positive for rhinovirus and was placed on droplet precautions. She was given normal saline 1 liter bolus and was discharged home on day #3.

The requested health service was not medically necessary.

An inpatient level of stay was not medically necessary since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have any complications such as intra-abdominal abscess or a surgical abdomen, and did not have hemodynamic instability. The patient also did not have severe pain requiring acute inpatient management, did not have peritoneal signs, did not require identification of etiology or finding, did not have suspected toxic megacolon, and did not have bacteremia. In addition, the patient did not have fulminant hepatic failure / elevated international normalized ratio (INR) / coagulopathy as a result of liver disease. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity ulcers.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of diabetes mellitus type 1 (DM1) complicated by gastroparesis and neuropathy who was admitted with complaints of (c/o) bilateral lower extremity (LE) ulcers with serosanguinous drainage after being sent from the vascular clinic for infectious disease (ID) evaluation after they determined no abscess; the patient recently completed a course of doxycycline. The physical exam was notable for the left lateral calf (1x1 millimeter (mm)) and right heel ulcer, neither with drainage. Imaging studies included a lower extremity (LE) radiograph that showed no soft tissue gas or osteomyelitis, or diffuse edema. The patient was diagnosed with complex pain and possible cellulitis and treated with wound care, opioids, gabapentin, and clindamycin. Vascular surgery evaluated the patient and determined no abscess and recommended no surgical intervention. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with complaints of (c/o) bilateral lower extremity (LE) ulcers with serosanguinous drainage. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, significant leukocytosis, did not meet systemic inflammatory response syndrome (SIRS) criteria, there was no animal or human bite with extensive damage, high-risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. There was mention of mild diabetic ketoacidosis (DKA) in the admission history and physical (H&P), but the patient was hemodynamically stable, and there was a readily treatable cause of hyperglycemia. This patient was diagnosed with complex pain, not cellulitis, and treated with wound care, neuropathy and pain control, continuation of home insulin regimen, and expert consultations who felt that the patient did not have cellulitis or required surgical intervention, and this could have been safely provided at a lower level of care. A lower level of care is ideal for the management of mild cellulitis infections because it allows frequent reevaluation to assess response to therapy while avoiding inpatient admission, while this patient primarily suffered from pain secondary to neuropathy and not cellulitis. Overall, this patient could have been safely treated at a lower level of care.