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

Diagnosis: Chest Pain (angina)
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult female. She presented with atypical chest pain for several days and dizziness for over a month. She was admitted to inpatient care. She was markedly hypertensive and treated with oral medications. Chart noted "concerned" for angina. The patient's pain resolved, and the patient ambulated. An incomplete stress test was considered low suspicion for coronary artery disease (CAD). The patient was discharged on oral anti-hypertensives with follow-up planned in one to two weeks as an outpatient. The health plan denied coverage of the inpatient admission as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. In this patient's case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. The patient's exam and cardiac findings were normal - the patient's blood pressure normalized. Her biomarkers and electrocardiogram showed no evidence of acute ischemia. The "abnormal EKG [electrocardiogram]" was premature ventricular contractions (PVCs) without abnormal repolarization. The patient's chest X-ray was normal. Echocardiogram showed no wall motion abnormality. The patient's stress test was negative for coronary artery disease (CAD). The physicians' treatment did not reflect any serious concern about the patient's cardiac condition. Orders did not include medical therapy for acute coronary syndrome, such as intravenous heparin, dual antiplatelet inhibitors, high dose beta blockers, or intravenous nitroglycerin. The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no "complex" care that required inpatient level of care in this patient's case. This patient had no evidence of coronary artery disease. In fact, all tests showed absence of ischemia. While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. There were no tests or therapy actually performed that would not be safe at a lower level of care. Milliman criteria requirements were not fulfilled, as there was never any evidence of acute coronary syndrome present. That diagnosis was ruled out. All testing and therapy would have been appropriate, safe, and guideline-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary. The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pneumonia.
Treatment:  Inpatient stay.

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

This is a case of a female admitted for diagnoses of pneumonia and sepsis. The patient presented with a chief complaint of generalized body aches, nasal congestion, headache, loss of appetite, myalgias, fever, cough and sore throat. Vital signs demonstrated blood pressure 104/78, pulse 108, temperature 100.8 (degree) F (Fahrenheit), respiratory rate 17 and O2 (oxygen) saturation 100% (percent). Physical exam showed non-toxic appearing female that was diaphoretic. There was no altered mental status. White blood cell count was 10.5 with hemoglobin 11.4. Creatinine was 1.1. A computed tomography (CT) of the head was unremarkable. Chest x-ray showed findings unlikely to be infiltrate. 

The inpatient hospital admission was not medically necessary.
The patient in this case was admitted for community acquired pneumonia and sepsis. She had a pulse of 108 and temperature 100.8F (Fahrenheit). It was noted that she did not have acute organ dysfunction. She had elevated total protein, but this was a chronic condition. The pneumonia severity index calculation placed her at risk class 2 with a 0.6 to 0.9% (percent) mortality rate. This is acceptable for outpatient treatment. Infectious disease evaluated her, and she was able to be converted to oral medication including doxycycline and cefpodoxime. There was no hemodynamic instability.
Although the patient required services in the hospital setting the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough, Difficulty Breathing
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with cerebral palsy, seizure disorder, lissencephaly, microcephaly, and global developmental delay due to congenital Zika virus who presented to the emergency department (ED) with complaints of a cough and runny nose with difficulty breathing. The patient was non-verbal and non-ambulatory. He takes an oral pureed diet. He was brought to the ED by Emergency Medical Services (EMS) who reported an oxygen saturation (O2 sat) of 92 percent (%) at home.
The exam noted a thin male with increased tone and acute distress. There was congestion, rhinorrhea, tachycardia, tachypnea, retraction, and wheeze.  A chest x-ray reported streaky airspace disease. The patient was treated with intravenous fluids (IVF), methylprednisone, Duoneb (ipratropium-albuterol) times (x) 3, intravenous (IV) ceftriaxone, and acetaminophen. The patient was admitted to the hospital for management of pneumonia. He was continued on albuterol, oral prednisone, and ceftriaxone. He was briefly on 2 liters (L) of oxygen due to an O2 sat of 92% and was to room air by the day after admission. He was discharged home on oral antibiotics.
At issue is whether inpatient hospitalization was medically necessary.
The requested inpatient hospital admission is medically necessary for this patient. This is a child with severe developmental delay and medical complexity related to congenital Zika infection. He is underweight, non-verbal, and non-ambulatory which puts him at increased risk for complication and poor outcome related to infection. He had abnormal vital signs of tachypnea and tachycardia, even when afebrile. His exam noted acute respiratory distress. The risk for readmission or failure of home treatment was great, and inpatient admission to ensure the ability to tolerate oral medications and stability in the home setting was medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease. 
Treatment: Rental of a home ventilator (E0466 for 12 units) - device that helps breathe while sleeping. 
The insurer denied coverage for rental of a home ventilator (E0466 for 12 units) - device that helps breathe while sleeping. 
The denial is upheld. 

The patient has a history of severe chronic obstructive pulmonary disease (COPD) who was on 5-6 liters of oxygen via nasal canula at home. The patient's medications include Trelegy Ellipta, Theophylline sustained release (SR), Montelukast, B2 as needed (PRN), and DuoNebs via nebulizer PRN. The patient also has a Smart Vest. The patient reported a few hospitalizations with COPD exacerbations. No pulmonary function tests (PFTs) were provided. No arterial blood gas (ABG) was provided. The patient's physician prescribed a portable home ventilator, Life 2000.

There is no documentation that this patient was prescribed continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) for nocturnal ventilation at home. There is no documentation that this patient has a neuromuscular disease or restrictive thoracic disease. There is no documentation that this patient has chronic respiratory failure with hypercapnia with a partial pressure of carbon dioxide (PaCO2) > 52 while aware and breathing room air (RA) or prescribed fraction of inspired oxygen (FiO2) and/or oxygen (O2) saturations less than or equal to 88% for at least five consecutive minutes during sleep oximetry while receiving oxygen at 2 liters per minute (LPM) or prescribed FiO2, whichever is higher. There is also no documentation that the patient had failed home non-invasive ventilation (NIV) with CPAP or BiPAP or that obstructive sleep apnea (OSA) has been considered and ruled out. 

Based on the above, the prescription for Portable Home Ventilator Life 200 cannot be approved. 

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 rental of a home ventilator (E0466 for 12 units) - device that helps breathe while sleeping is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with hypertension who presented to the emergency department for evaluation of headache that started one day prior. The patient also endorsed numbness and subjective weakness in the left arm, although this was noted to be a chronic problem. The patient underwent a computed tomography (CT) scan of the head that was unremarkable. A computed tomography angiography (CTA) of the head and neck showed intracranial stenosis. The radiologist questioned vasculitis. The patient was admitted to the hospital for further evaluation. 

The inpatient hospital admission was not medically necessary. The patient presented to the hospital for evaluation and treatment of a headache. The patient also complained of left arm, numbness and heaviness, although this was a chronic complaint. The patient was evaluated by imaging for a headache. The patient was found to have multi focal stenosis or narrowing of the cerebral blood vessels. It was questioned as to whether the patient had reversible cerebral vasoconstriction syndrome. Evaluation by MRI of the brain showed no acute findings. A lumbar puncture to look for inflammation was also unremarkable. The patient was treated for a possible vasoconstriction syndrome with verapamil. The patient's headache had improved even prior to treatment. The patient elected for no further treatment, and to leave the hospital. Acute inpatient admission is not warranted. The patient was treated for a previously discovered findings of intracranial stenosis. The patient did not have any significant neurologic deficits. The patient did not have any acute findings on imaging. The patient did not have any significant laboratory abnormalities. The patient's headache improved during the observation timeframe. All of these suggest that the patient could have been appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: slurred speech
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with a past medical history of a transient ischemic attack, schizophrenia, hypertension, and diabetes mellitus who initially presented to his provider's office for a routine visit and was subsequently directed to the emergency department for concerns of slurred speech. Initial vital signs revealed a temperature of 98.6  Fahrenheit degree, heart rate (HR) 87, blood pressure (BP) 110/74, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 98% (percent) on room air. Initial examination documented the patient as alert and oriented with mildly slurred speech. An electrocardiogram (EKG) unremarkable. Urinalysis was unremarkable. Computed tomography (CT) head imaging unremarkable. The patient was placed in the hospital thereafter. 

The inpatient hospital admission was not medically necessary. The patient had a history of a transient ischemic attack and schizophrenia who was directed to the emergency department for concerns of dysarthria. Initial examination documented the patient as alert, oriented, and with mildly slurred speech. Initial evaluation revealed unremarkable laboratory testing and CT brain imaging. The admitting physician documented resolution of slurred speech with a NIHSS (The National Institutes of Health Stroke Scale) of 0. Treatment plan included additional diagnostic testing. Neurology consulted, documented resolution of presenting symptoms, and agreed with further diagnostic testing. The echocardiogram and magnetic resonance imaging (MRI) brain were unremarkable. Symptoms did not recur. Following observation care, the patient was at baseline state of health without additional issues or complications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain and Gallstones.
Treatment:  Inpatient admission.

The insurer denied: Inpatient admission.  The denial is upheld.

The patient is an adult female with a history of chondromalacia of the knee, chronic neck and back pain, and migraines. She presented to the emergency room with intermittent right upper quadrant abdominal pain for the prior two weeks and reports of nausea and vomiting, with the last episode of vomiting having been the day before. The patient stated that that she was seen by her primary care, and her liver enzymes were noted to be abnormal. She also had an ultrasound, which showed an inflamed liver and pancreas. Physical exam was notable for abdominal tenderness in the right upper quadrant, Murphy's sign and jaundiced skin. CT (computed tomography) and ultrasound were done in the ED (emergency department), as the patient had hyperbilirubinemia (total bilirubin of 1.6). She was started on IV (intravenous) fluids and was made NPO (nothing by mouth). Subsequently, MRCP (Magnetic Resonance Cholangiopancreatogram) was done on day # (number) 2, which showed no dilation of the biliary tree. MRI (magnetic resonance imaging) specifically showed status post cholecystectomy. No dilatation of the biliary tree was noted. No filling defects within the biliary tree were noted. On this MR (magnetic resonance), there are multiple small calcifications adjacent to the right hepatic lobe as seen on the CT (computed tomography), particularly those seen along the lateral margin of the right hepatic lobe, which are identified on MR (magnetic resonance) by the signal loss on both the T1W (spin-lattice relaxation time) and T2W (spin-spin relaxation time) MR (magnetic resonance) images. There is no evidence of fluid collection to suggest abscess associated to the calcifications. The patient's diet was advanced as tolerated, and pain was well controlled with PO (oral) medications. The patient was admitted the day after presentation and discharged on day #4.

The Inpatient admission was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question, as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myotonic muscular dystrophy.
Treatment: Increase in personal care services from 84 hrs per week to 24 hours (hrs) per day (split shift).
The insurer denied increase in personal care services from 84 hrs per week to 24 hours (hrs) per day (split shift).
The determination is upheld.

The patient is a female with a past medical history of myotonic muscular dystrophy, anxiety, hypertension, hyperlipidemia, insomnia, depression, osteoarthritis, diabetes mellitus type 1, vitamin B deficiency, vitamin D deficiency, constipation, bladder incontinence and bowel incontinence who had been assigned personal care assistant (PCA) services 84 hours/week based on an assessment. A tasking tool estimated 49 hours/week.
There was a request to increase PCA services and the patient underwent a telephonic assessment. Notes from the assessment stated the patient used a rollator walker with assistance while indoors and a wheelchair pushed by others when outdoors. The tasking tool estimated 61.83 hours/week.
The insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services stating the patient's medical diagnoses and were unchanged and her medications were only minimally changed. The patient's health care advocate provided a letter reiterating the patient's case and noting the patient is unable to change position in bed and her neurologist noted in a letter that the patient needed to be repositioned every 2 hours as the patient was unable to move on her own. The healthcare advocate's letter also noted the patient's husband was unable to provide overnight support of care needs. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient was unable to move her legs and is bedridden and the patient required assistance with bathing, dressing, position changes, toileting, medication administration, glucose monitoring, insulin administration, shopping, and meal prep. The letter also stated it was medically necessary for the patient to receive 24-hour aide services. At issue is the medical necessity of increase in personal care services from 84 hrs per week to 24 hours (hrs) per day (split shift).

No, the requested services are not medically necessary. Although there is mention of a note from a neurologist by the patient's healthcare advocate it was not available for review and therefore, there is no documentation of medical necessity of split shift services such as turning and repositioning every 2 hours, overnight care logs, or documentation that there is not physical space for a PCA to obtain sleep. There is no documentation of overnight care needs that would not allow a PCA 5 hours of uninterrupted sleep. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, split-shift, are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: subcutaneous abscess 
treatment: air ambulance
The insurer denied the air ambulance
The health plan's determination is upheld. 

This is a male who presented with fever, neck pain, nausea and headache. He had recently been admitted for a cervical spinal cord revision. He had drainage at the surgical site and underwent removal of the spinal cord stimulator and generator. The cultures from the surgery showed methicillin-susceptible staphylococcus aureus (MSSA). He apparently had a computed tomography (CT) scan showing a possible subcutaneous abscess and was to be transferred to a higher level of care. 

The Rotary Wing Air Transport (Air Ambulance) and Mileage was not medically necessary. The patient did not have an epidural abscess, but rather had an abscess potentially in the subcutaneous tissues. This did not require emergency intervention. Additionally, the patient had a normal neurological exam with no neurological symptoms. The patient could have been transported by ground transport without risk. The patient had already been on antibiotics and the infection was previously diagnosed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: back pain
Treatment: Pain Management Injection (CPT 62323) 
The insurer denied Pain Management Injection (CPT 62323) 
The health plan's determination is upheld. 

The patient is a female with chronic low back pain. The pain radiates down her feet. She has undergone prior L (lumbar) 4-L5 lumbar epidural injection with substantial relief. Her medications include hydrocodone. Magnetic resonance imaging (MRI) lumbar spine 2019 demonstrates L4-L5 degenerative changes. There is a plan for an epidural injection. This is under review.

The Pain Management Injection (CPT 62323) is not medically necessary for this patient.
Although it is acknowledged that the patient has radiating low back pain, the documentation provided does not substantiate an acute exacerbation of lumbar radiculopathy. The patient has chronic lumbar radicular symptomatology, for which an epidural injection is not medically necessary. The use of epidural injections for chronic radiculopathy is not supported in the literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Club feet
Treatment: Durable medical equipment (DME) (L1940 x [times] 2, L2275 x 2, L2280 x 2, L2840 x 2)
The insurer denied coverage for DME (L1940 x 2, L2275 x 2, L2280 x 2, L2840 x 2).
The denial is overturned.

This case involves a pre-teen child with a request for durable medical equipment (DME) (L1940 x [times] 2, L2275 x 2, L2280 x 2, L2840 x 2). The patient was seen for a follow-up visit regarding bilateral club feet in the setting of schizencephaly. The patient was noted to have a history of seizures that were well controlled with medication. It was reported that the patient continues to wear bilateral ankle-foot orthoses and can ambulate without the orthoses, however, he sometimes trips when he is not wearing the orthoses. On exam, the patient was noted to walk up on his toes, with residual right hindfoot varus and tightness of the Achilles. The treatment plan included new floor reaction braces with a supramalleolar orthosis (SMO) component, and possible Achilles tendon lengthening surgery in the future when the patient is done growing.

A letter of medical necessity signed by the patient's physician indicated that the patient has a diagnosis of schizencephaly with ill-fitting ankle-foot orthoses. It was stated that the current ankle-foot orthoses cannot be repaired, as the patient has grown several inches taller. The treating physician also stated that the patient requires new floor reaction ankle-foot orthoses with an SMO component to allow continued maintenance of alignment and current ambulation ability. 

Documentation provided by the insurer indicates ankle-foot orthoses are covered for members when specific criteria are met: the patient could not be fit with a prefabricated ankle foot orthosis (AFO), the condition necessitating the orthosis is expected to be permanent or of long standing duration, there is a need to control the knee, ankle, or foot in more than 1 plane, the patient has a documented status that requires custom fabricating over a model to prevent tissue injury, or the patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions. 

This pediatric patient has a history of schizencephaly related bilateral club foot that has continued to be treated with ankle-foot orthoses. It was stated that the patient has grown several inches and as such, his current orthoses no longer fit. On exam, the patient had residual right hindfoot varus and tightness of the Achilles. The requested orthoses are medically necessary to prevent falls and regression of maintained alignment due to ill-fitting orthoses. 

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

The medical necessity for DME (L1940 x 2, L2275 x 2, L2280 x 2, L2840 x 2) services is substantiated.