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

Diagnosis: Lower Extremity Claudication
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient has a family history of coronary and vascular disease and a past medical history of hyperlipidemia, smoking, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, and percutaneous intervention. She had bilateral lower extremity claudication. She had a recent percutaneous intervention of a right superficial femoral artery (SFA) stenosis. The numbness in her right leg had improved and she still had ongoing bilateral lower extremity claudication. She presented for elective lower extremity angiography. The left ventricular ejection fraction (LVEF) was normal. The blood pressure (BP) was mildly elevated. Other vital signs and the oxygen saturation were normal. She was in no acute distress. She underwent a successful and uncomplicated lower extremity percutaneous intervention. She remained stable and was discharged. The creatinine was 0.58. An inpatient level hospitalization is under review for medical necessity.

This patient underwent successful elective and non emergent lower extremity arterial stenting without complications, and was monitored for an adequate post procedure period. There were no vascular complications, hemodynamic instability, acute or recurrent limb ischemia, need for further emergent surgery, or need for prolonged intravenous medications. The creatinine was normal. In this setting it has been demonstrated that peripheral arterial stenting can be accomplished adequately, and without increased risk or complications, in the outpatient setting, without the need for an inpatient or observation level hospitalization. Therefore, the inpatient hospitalization is considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult female who presented to the emergency department (ED) with abdominal pain. The patient has a history of cholelithiasis, diabetes mellitus (DM) and hypertension, and presented with right upper quadrant (RUQ) pain since the previous night. She reported biliary colic for the last month. She vomited twice the night prior to admission and was nauseous. She denied fever or chills. She was afebrile with vital signs stable. On exam she did not have abdominal tenderness. There was no costovertebral angle (CVA) tenderness, guarding or rebound. The assessment was biliary colic versus cholelithiasis versus cholecystitis. The ultrasound on admission did not show gallstones or common bile duct (CBD) dilation. However, the emergency department (ED) provider noted that the patient recently had imaging which showed gallstones. She also had elevated bilirubin concerning for choledocholethiasis. 

The white blood cell (WBC) count was normal at 8.4. Total bilirubin was 2.1, Alanine Transaminase (ALT) was 89 and Aspartate Aminotransferase (AST) was 107. Her body mass index (BMI) was 42.06.

It was noted that upon direct review of the ultrasound there was sludge on the ultrasound. But there was no evidence of cholecystitis. There was mild to moderate increased hepatic echogenicity consistent with diffuse hepatocellular disease, most frequently steatosis.

The patient underwent laparoscopic cholecystectomy on day 2 of admission. Surgery was uneventful and pathology revealed chronic cholecystitis with cholelithiasis. Recovery was uneventful. This surgery and the recovery time are usually done in one day. Sometimes they watch the patient overnight after this surgery (observation care). There are no notes that the patient had problems after the surgery. They are no notes that the patient had an unstable heart rate or blood pressure after treatment. There are no notes that the patient could not eat or drink liquids or that the pain was not controlled. 

According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 27th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The patient did not have any MCG criteria indication for acute inpatient admission. 

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 the inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: frequent falls
Treatment: Personal Care Aide (PCA) Services: 7 Days per Week x (times) 12 Hours per Day + 7 Days per Week x 12 Hours per Day: Total of 168 Hours per Week (Split Shift)
The insurer denied Personal Care Aide (PCA) Services: 7 Days per Week x 12 Hours per Day + 1 Days per Week x 12 Hours per Day: Total of 168 Hours per Week (Split Shift).
The health plan's determination is upheld. 

This is a female patient with a history of dementia, coronary artery disease, hypertension, hyperlipidemia, essential thrombocythemia, osteoporosis, depression, gout, and urinary incontinence. She is currently admitted to a short-term rehab facility after a fall. Prior to being admitted to short term rehab, the patient lived alone in a one-bedroom apartment. 

Personal Care Aide (PCA) Services: 7 Days per Week x 12 Hours per Day + 7 Days per Week x 12 Hours per Day: Total of 168 Hours per Week (Split Shift) are not medically necessary for this patient.
Although the patient requires hands-on assistance with many activities of daily living (ADL) and Instrumental activities of daily living (IADL), the documents provided do not support medical necessity for split-shift care. Split shift care is indicated if a live-in personal care aide would not be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep due to a patient requiring assistance with ADLs. There is no documentation showing that the patient currently requires frequent overnight assistance with specific ADLs or IADLS. There were no night-logs of care required overnight and no physician orders for frequent repositioning. The main reason given by the patient and her son for split-shift care is a history of recurrent falls with injury. However, additional hours are not provided when tasks are not being performed and for safety monitoring and supervision only. The PCA agency's inability to provide an aide for 24-hour shifts does not constitute medical necessity for split-shift care. Therefore, there is insufficient evidence for the medical necessity for split-shift care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission
The denial is : Upheld
The patient presented with abdominal pain and vomiting. The patient had a recent lyomectomy with uterine polyp removal. The patient was taking Ketorolac. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The surgical site was intact. There was no leukocytosis. The hemoglobin (Hgb) was 10.3. An abdominal computed tomography (CT) scan suggested duodenitis. Proton pump inhibitor (PPI) therapy was given. The patient's symptoms improved. 

Clinical indications for admission for Gastritis and Duodenitis (MCG Milliman Care Guideline M-560) include hemodynamic instability, gastric outlet obstruction, perforation, peritoneal signs, severe vomiting that is not responsive to antiemetics, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bowel perforation or obstruction, bacteremia, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient was taking Non-steroidal anti-inflammatory drugs (NSAID's) and developed duodenitis. The patient required PPI therapy, IV (Intravenous) hydration, antiemetics, and PPI therapy could have been given with observation care. The patient did not meet Milliman Care Guidelines (MCG) criteria for admission for either Gastritis and Duodenitis or Undiagnosed Abdominal Pain. The denial is upheld.

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

Diagnosis: Croup
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld

This is an infant with a history of a viral illness with fever. The child had been seen twice by her pediatrician and she was diagnosed with roseola 3 days before the admission to the hospital. The night before admission the patient was noted by the parent to have a cough and wheezing which became worse during the night. When the patient was noted to have difficulty breathing the parent's brought the patient to the Emergency Room (ER) for an evaluation.

In the ER the child was noted to have inspiratory stridor and some chest congestion. The pulse oximeter reading was 96 percent (%) on room air. The child was treated with a racemic Epinephrine treatment and there was some improvement noted in the stridor. When the stridor did not completely resolve a second treatment of racemic Epinephrine was administered. In addition, the child received a bolus of intravenous (IV) normal saline at 20 cubic centimeters/kilogram (cc/kg), oral Dexamethasone and 2 treatments with a bronchodilator for chest congestion. A chest radiographic image (x-ray) was normal. Blood testing was significant for a low carbon dioxide (CO2) level of 17. Because the patient required 2 treatments with racemic Epinephrine the decision was made to admit to the hospital for observation and normal saline nebulizer treatments every 3 hours as needed (PRN) if the patient developed worsening respiratory symptoms. The patient did not require treatment with oxygen.

The insurer denied the need for admission to the hospital and indicated that the child could have been safely discharged.

The patient was treated appropriately in the emergency room (ER) for an acute illness diagnosed as croup. There was improvement following two treatments with 2 doses of racemic Epinephrine and the patient was breathing comfortably. The patient had also been treated with one dose of oral Dexamethasone. Following treatment in the ER the patient improved and there was no persistent stridor of respiratory distress. The oxygen saturation was normal, and the patient did not require treatment with oxygen. The patient responded to treatment and was stable enough to be discharged home with a follow-up visit with the pediatrician in 24- 48 hours. The admission to the hospital was not consistent with the standard of care for treatment of croup.

The only abnormal value from her lab testing was a low CO2 level of 17 but this was not considered a reason for admission and there was no note or referral to this result in the patient's problem list which would have indicated the need for admission for additional intravenous (IV) fluid administration.

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 an inpatient is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II Division 1 malocclusion 
Treatment: Braces and Monthly Visits (x4) 
The insurer denied Braces and Monthly Visits (x4) 
The health plan's determination is overturned.

The patient in question is a male with a Class II Division 1 malocclusion with maxillary and mandibular crowding. He has 7 millimeter (mm) overjet and 2 mm overbite. Tooth 31 is impacted. He is treatment planned for Braces and Monthly Visits (x4).

Braces and Monthly Visits (x4) are medically necessary for this patient.
Teeth # (number)8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ (plus)mm overjet, which this patient has.
The patient also has an impacted mandibular right second molar. Side effects of impacted mandibular second molars include a significant increase in periodontal defects distal to the erupted first molars due to the inadequate development of bone in that region as a result of the impacted tooth. No treatment will put the mandibular right first molar (tooth 30) at risk. The requested orthodontic treatment is medically necessary due to the overjet and the impacted mandibular right second molar.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Retained products of conception and severe anemia status-post D&C
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The patient is a female who presented to the Emergency Department (ED) with prolonged vaginal bleeding for 7 days. The patient was diagnosed with retained products of conception and severe anemia. The patient was transfused with 2 units packed red blood cells (PRBC's) and underwent a dilation and curettage (D&C). Blood loss was heavy during the D&C necessitating transfusion with 1-unit PRBC's and 1-unit fresh frozen plasma (FFP). Postoperatively, the patient received one more unit of PRBC's. On post-operative day 1, the patient was still anemic and received 1 more unit of PRBC's.

While D&C's and transfusions are ambulatory procedures, this patient was unstable to undergo a D&C necessitating admission for stabilization prior to surgery. During the procedure the patient had obstetrical hemorrhage necessitating blood and FFP transfusions.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include: Active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. The patient was unstable and had significant hemorrhage. A blood loss of 1000 cubic centimeter (cc) for a first trimester D&C is excessive and the admission for stabilization, D&C, bleeding control and aggressive management was warranted and medically necessary.

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



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

The patient is a male who is an active smoker with a medical history of hypertension, hyperlipidemia, pre-diabetes, and asthma without a history of previous intubation. He was admitted for an asthma exacerbation secondary to pneumonia with symptoms of shortness of breath, a non-productive cough, and chest pain/tightness. Of note, the patient was seen on each of the previous 4 days in the emergency room, treated with nebulizers/steroids, and subsequently released. On chest x-ray, he was found to have a left lower lobe opacity likely representing pneumonia. 

The inpatient admission was medically necessary for this patient.
This patient with a medical history of hypertension, hyperlipidemia, pre-diabetes, and asthma without a history of previous intubation was admitted for an asthma exacerbation secondary to pneumonia with symptoms of shortness of breath, a non-productive cough, and chest pain/tightness. On initial presentation to the emergency room, he was hemodynamically stable with an oxygen saturation of 96% on room air but he had tachypnea, accessory muscle use, a respiratory rate of 20 breaths per minute, and on auscultation of the chest, diffuse wheezing. On chest x-ray, he was found to have a left lower lobe opacity likely representing pneumonia. In addition, his peak flow was measured at 100, which is less than 25% of the predicted (baseline 450). Based on an acute asthma exacerbation due to pneumonia, along with a peak of less than 25% of his baseline, the inpatient admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, fibromyalgia, chronic obstructive pulmonary disease (COPD), and diabetes
Treatment: home delivered meals - individual entree: 3 units per day - 7 days per week - a total of 21 units per week
The insurer denied coverage for: home delivered meals - individual entree: 3 units per day - 7 days per week - a total of 21 units per week
The denial is: Overturned

The patient has diagnoses of osteoarthritis, fibromyalgia, chronic obstructive pulmonary disease (COPD), and diabetes. It is reported that the patient has chronic pain, weakness, and limited range of motion (ROM). The patient needs weight bearing assistance with bathing and getting dressed. The patient states that they are unable to set the table for meals or to be involved in meal preparation. The patient receives consumer directed personal assistance services (CDPAS) for 42 hours a week and has received public assistance through Supplemental Nutrition Assistance Program (SNAP) but this does not cover proper nutrition for the month. 

Medical necessity was determined based on New York State guidelines from the Office for the Aging on the topic of Food and Meals. The guideline discusses eligibility. If you are 60 years old or older and have completed an interview and are not able to prepare meals for yourself, you are eligible for this program if you don't have adequate help from a friend or family. This is not an income-based program. The patient met this criteria.

This patient is receiving help with preparation of meals but is unable to care for themself. The patient reports financial difficulty with obtaining proper meals. The New York State program is designed to provide healthy, nutritious, balanced meals for senior citizens. The patient has a need for the Meals on Wheels program. The patient is unable to care for themself and requires proper nutrition. Home delivered meals are medically necessary. The denial is reversed.

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 home delivered meals - individual entree: 3 units per day - 7 days per week - a total of 21 units per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic obstructive pulmonary disease.
Treatment:  Inpatient Hospital Stay.

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

This is a male patient, who initially presented to the emergency department with concerns for shortness of breath. The pertinent history included chronic obstructive pulmonary disease, hypertension, and diabetes mellitus.  The initial examination documented the patient as alert and oriented with non-labored respirations. Computed tomography angiography (CTA) of the chest did not reveal a pulmonary embolism but did reveal findings suggestive of bilateral pneumonia. The patient was admitted to the hospital with an impression of community acquired pneumonia and acute exacerbation of chronic obstructive pulmonary disease. The treatment plan included empiric antibiotics, nebulizers, and corticosteroids. Bilateral expiratory wheezes persisted. Antibiotics were broadened to Zosyn. SoluMedrol and nebulizers were continued "around-the-clock". He had continued shortness of breath, but improved. Antibiotics were adjusted again to ceftriaxone monotherapy. The patient was discharged. At issue is the medical necessity of an inpatient hospital admission.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was medically necessary for the entire admission.
Wedzicha et al. note the chronic and progressive course of chronic obstructive pulmonary disease (COPD) is often punctuated by "exacerbations", defined clinically as episodes of increasing respiratory symptoms, particularly dyspnea, cough and sputum production, and increased sputum purulence. COPD exacerbations have a negative impact on the quality of life of patients with COPD, accelerate disease progression, and can result in hospital admissions and death.[1]

The patient had a history of chronic obstructive pulmonary disease who presented with shortness of breath. Initial examination documented the patient as alert, tachycardic, and with bilateral expiratory wheezes. Initial evaluation revealed a leukocytosis and CT findings suggestive of bilateral pneumonia. Treatment included empiric antibiotics, bronchodilators, and systemic corticosteroids. Due to ongoing symptoms and an increasing white blood cell count, antibiotics were broadened on two separate days and systemic corticosteroids were continued. After multiple days of treatment, the patient continued to have dyspnea with exertion below baseline. The clinical indications for admission to inpatient care were met. The patient had new signs or symptoms of COPD (dyspnea, cough, and sputum production) that persisted despite appropriate observation care.[2][3]