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

Diagnosis: Cancer. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female with right breast cancer for which she underwent a right mastectomy and tissue expander reconstruction. She was seen in the plastic surgery clinic at which time she had reported several days of worsening right breast pain with fever and nausea. 

On exam, she was noted to have a surgical site infection and she was sent to the hospital in preparation for operative washout. The patient presented to the Emergency Department in the early evening on where she was noted to be in no acute distress with temperature of 99.5 degrees Fahrenheit (F), heart rate 105 beats per minute (bpm), blood pressure (BP) 112/74. On exam, the right mastectomy site was noted to have an area of central wound dehiscence and purulent discharge with mild surrounding erythema and tenderness to palpation. The patient was initiated on intravenous (IV) antibiotics and admitted to the hospital. She was brought to surgery in the evening for washout of her right mastectomy site with replacement of her tissue expander and primary closure. She tolerated the procedure well and was monitored on the general nursing care floor. The next morning, she was deemed ready for discharge to home. The question at hand is whether an inpatient stay was medically necessary during this clinical encounter. 

The health plan's determination is upheld in whole. 

An inpatient hospital stay was not medically necessary. The care that was provided was entirely appropriate including her hospital stay, operative intervention, and IV antibiotics. While the operative intervention, IV antibiotics and pre- and post-operative care needed to be provided in the hospital, the level of care in the hospital did not need to be the acute inpatient level of care. Acute inpatient level of care would have been indicated if the patient had presented with hemodynamic instability and/or signs of sepsis, for instance. Given that the patient was clinically stable throughout her hospital stay, she could have received the identical clinical services at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is overturned in whole. 

This is a male with a history of alcoholic cirrhosis complicated with Esophageal varices status/post (s/p) banding. He presented with left-sided abdominal pain. On admission, the complete blood count (CBC) revealed mild anemia and thrombocytopenia, a computed tomography (CT) scan revealed splenomegaly and new liver lesion concerning for hepatocellular carcinoma (HCC), and non-occlusive thrombus in the proximal Superior Mesenteric Vein (SMV). 

He received intravenous (IV) analgesics for the management of his pain. Vascular surgery was consulted regarding his SMV thrombus and recommended against surgical intervention. A gastrointestinal (GI) consultation recommended further imaging with a magnetic resonance imaging (MRI) scan /magnetic resonance venography (MRV) of the abdomen for evaluation of the new liver lesion concerning for HCC. Additionally, GI recommended further workup of acute cirrhotic decompensation including hepato-renal syndrome workup, interventional radiology (IR) consultation for ultrasound guided diagnostic paracentesis and empirical intravenous (IV) antibiotics for management of spontaneous bacterial peritonitis (SBP) and underwent a diagnostic and therapeutic esophagogastroduodenoscopy (EGD) with banding of varices. Hematology was consulted for anticoagulation management of new SMV thrombus but recommended against anticoagulation. 

At issue is the medical necessity of the inpatient stay. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Inpatient Stay was medically necessary for this patient. 

This is a male with a history of alcoholic cirrhosis complicated with Esophageal varices who presented with new onset abdominal pain in the setting of new liver lesion, and non-occlusive SMV thrombus concerning for acute liver decompensation. His clinical presentation required inpatient care for urgent evaluation for precipitant (SMV thrombus, new liver lesion) for his acute liver decompensation and aggressive management of signs and symptoms of acute liver decompensation, spontaneous bacterial peritonitis, ascites, Hepato-renal syndrome, and liver cancer. 
This patient required multidisciplinary consultation and prevention of liver decompensation with diagnostic paracentesis, empiric IV antibiotics to prevent SBP, diagnostic EGD with variceal banding to prevent variceal bleeding. The detailed inpatient medical management (multidisciplinary consultations, serial labs, diagnostic and therapeutic endoscopy with variceal banding, diagnostic radiology imaging, diagnostic IR guided paracentesis, empiric IV) cannot be appropriately and prudently provided for this complex patient under any level of care other than the inpatient level of care. 

Therefore, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia.
Treatment: Personal Care Services for Eight Hours a Day, Seven Days a Week for a Total of 56 Hours per Week.
The insurer denied the Personal Care Services for Eight Hours a Day, Seven Days a Week for a Total of 56 Hours per Week.
The denial is upheld.

This patient is a female with conditions including Alzheimer's dementia.  She is appealing denial of Personal Care Services for eight hours a day, seven days a week, for a total of 56 hours per week.  The Plan has approved personal care services (PCS) five hours a day, seven days a week, for 35 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and supervision with bed mobility and eating.  

An appeal letter from the provider notes the patient needs eight hours a day of supervision to keep her safe.  An appeal letter from another provider notes the patient has progressive declining dementia and has been exhibiting behaviors concerning for safety and eight hours home health aide (HHA) is needed for the patient's safety and well being.  It states the patient retains some functional independence.

No, the proposed treatment is not medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient has progressive Alzheimer's dementia.  She is appealing denial of Personal Care Services for eight hours a day, seven days a week, for a total of 56 hours per week.  The Plan has approved personal care services (PCS) five hours a day, seven days a week, for 35 hours per week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with meal preparation, housework, shopping, managing finances and medications, phone use, bathing, lower body dressing, personal hygiene, upper body dressing, walking, locomotion, and toileting.  Appeal statements note the patient has progressive decline in dementia and needs increased personal care services (PCS) for safety and supervision.  Personal Care Services (PCS) are not indicated for supervision.  The approved personal care services (PCS) 35 hours per week is appropriate and medically indicated to meets the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in personal care services (PCS) to total 56 per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Idiopathic Constipation.
Treatment: Motegrity 1MG OR TABS.
The insurer denied the Motegrity 1MG OR TABS.
The denial is upheld.

The patient female. She has the diagnosis of chronic idiopathic constipation. As treatment for this condition, the provider has requested the provision of Motegrity. The patient also has upper GI (gastrointestinal) symptoms of nausea. The plan declined coverage of this medication as there was no medical records provided to show that the patient had tried and failed treatments such as bisacodyl or senna preparations.

No, the requested Motegrity is not medically necessary.
The patient has not tried and failed many other alternatives for the treatment of chronic idiopathic constipation available on the plan formulary. There is no medical record to mandate the use of Motegrity over these other options.  The use of Motegrity is not indicated or supported for the treatment of upper GI (gastrointestinal) dysmotility symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease.
Treatment: Rytary 23.75-95MG OR CPCR.
The insurer denied the Rytary 23.75-95MG OR CPCR.
The denial is upheld.

The patient is a female with Parkinson's disease (PD). She is currently treated with Neupro and Rytary. The provider indicated she has tried and failed ropinirole, ropinirole ER (extended release) and rasagiline. The provider is requesting continuation of Rytary. This was denied coverage as she has not tried all of the preferred agents.

No, the Rytary is not medically necessary.

There is no documented reason as to why the patient cannot be treated with the preferred alternatives, such as carbidopa/levodopa CR (controlled release). These medications are FDA (United States Food and Drug Administration)-approved for her condition and considered first-line, standard-of-care treatment options (Zesiewicz; Poewe et al.). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Rytary relative to the preferred alternatives, such as carbidopa/levodopa CR (controlled release).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She has a past medical history significant for HTN (hypertension), DM (diabetes mellitus) Type 2, hypothyroidism, and Lymphoma, status post radiation therapy. She presented to the ER (emergency room) with new onset palpitations, dizziness, and dyspnea.

In the ER, the patient was found to be in atrial flutter with rapid ventricular response. Her heart rate was elevated to 120s. Her troponin was mildly elevated at 0. Her pro-BNP (brain natriuretic peptide) was elevated at 1176. ECG (electrocardiogram) was consistent with atrial flutter. Chest x-ray was unremarkable.

The patient was started on Heparin drip and Cardizem. She was subsequently switched to metoprolol. She was seen in consultation by cardiology. She was scheduled for TEE (transesophageal echocardiogram)-guided ablation of her arrhythmia. Following the procedure, the sinus rhythm had been restored, and the patient was discharged home on oral Eliquis and metoprolol.

Yes, the inpatient admission was medically necessary.

The patient presented with new onset symptomatic atrial flutter with uncontrolled heart rate. The laboratory data was consistent with end-organ damage, based on abnormal levels of cardiac troponin and pro-BNP. She required transesophageal echocardiogram and ablation procedure for control of her arrhythmia. Given the presentation, uncontrolled atrial flutter, as well as multiple comorbidities and clinical suspicion for end-organ involvement, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anaphylactic reaction

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This case involves a female who presented to the hospital due to an anaphylactic reaction. The documentation indicated she has been allergic to milk in addition to having a medical history including mild intermittent asthma and anxiety. She indicated she had gone out to eat and felt a tingling sensation to the back of her throat in addition to abdominal pain. The documentation detailed her mother gave her Benadryl and she stated she felt mild relief. Soon after she complained of worsening abdominal pain and detailed her throat felt scratchy. She has never previously been admitted into the hospital or intensive care unit, needed supplementation with oxygen or intubation due to anaphylaxis. She was initially given epinephrine in addition to Benadryl and Solu-Medrol with improvement of symptoms. However approximately 4 hours after emergency department presentation she complained of returning symptoms that included abdominal pain in addition to rash and hives. She received a second dose of epinephrine and was transferred to pediatric intensive care. On admission, she continued with Solu-Medrol and Benadryl and remained hemodynamically stable. She did not require any further dosing and had a complete resolution of symptoms. The following day she was examined and denied throat pain or abdominal discomfort. She did not have any rash or hives present. She was tolerating a diet and remained on room air. She was noted to be stable and therefore, she was discharged with instruction to follow-up.

According to current literature, a patient may be admitted when there is evidence of hemodynamic instability such as hypotension, tachycardia, bradycardia, or inadequate perfusion that is not readily corrected within the emergency department. The literature indicates a pediatric admission may also be appropriate when there is evidence of heart failure or severe respiratory findings such as respiratory distress. 

The submitted documentation indicated the patient was seen as a transfer from another facility due to an anaphylactic reaction to milk. The patient still had complaints of abdominal pain in addition to itchiness to her throat however, there was no significant airway compromise noted. While observation treatment was appropriate, it does not appear the patient's admission was needed.

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

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

Diagnosis: Vasculitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a woman with a history of tobacco abuse. She presented to the emergency department (ED) with complaints of a generalized rash for weeks, myalgias, arthralgias and polyarthralgia's. In the ED, vital signs were stable and oxygen saturation was 98% (percent). There was a maculopapular rash on the torso. The mouth was normal. There was wrist swelling. White blood cell (WBC) count was 19.3, felt to be reactive. A chest x-ray (CXR) and computed tomography (CT) scan of the chest, abdomen, and pelvis revealed a left ovarian cyst. She was given prednisone, Toradol, Pepcid, Lopamidol, Acetaminophen, intravenous (IV) fluids, IV Cefepime, and IV Vancomycin. The patient was admitted to Medicine with vasculitis. She was continued on 40 mg (milligrams) of prednisone once a day (QD). The maculopapular rash improved after a day of steroids. Rheumatoid factor was non-reactive. Infectious disease (ID) consulted over the case. No antibiotics were needed. Hematology noted that leukocytosis and thrombocytosis were likely reactive. X-rays of the wrists were negative. X-rays of the knees revealed joint effusion. Rheumatology recommended obtaining bloodwork and following up at the outpatient clinic. The patient was discharged with instructions to continue taking 40 mg of prednisone QD.    

The reviewer agrees with the insurer's decision.

The level of care supported was evaluated using Milliman Care Guidelines (MCG) for Musculoskeletal Disease and General Criteria: Observation Care. 

There was concern about infection due to high WBC, but no antibiotics needed to be given. The patient had cutaneous vasculitic lesions with no ulcerations or diffuse erythema. There was no mucosal or visceral involvement. The hospital response is correct in noting the potential for more severe involvement, but such problems did not evolve. Steroid treatment was oral, and she responded well.

The patient needed to be monitored to ensure that she was stable and responded to therapy. Treatment could have been considered as an outpatient, but the symptoms were new, and infection was part of the initial differential. This would support an Observation level of care, as proposed by the insurer. There were none of the severity of illness markers that would have supported an acute level of care. 

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

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

Diagnosis: Metastatic breast cancer
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient in this case has a history of metastatic breast cancer.  She had been on chemotherapy treatment, but records indicate that she had not seen a physician for several months.  She presented to the emergency department (ED) with nausea/vomiting, chronic right-sided abdominal pain and right anterior hip pain.  Evaluation revealed a left pubic bone pathologic fracture associated with a large lytic metastatic lesion.  Other lytic bone lesions were also identified.  Bilirubin and liver enzymes were also elevated.  She was admitted to the hospital for pain control and orthopedic evaluation.  

Imaging evaluation revealed widespread metastatic disease involving bones and liver.  Records indicate that she had a long history of bone and liver metastatic disease and that she had been lost to follow up on multiple occasions and was generally non-compliant with treatment recommendations.  She was seen by Oncology, who recommended that she follow up with her outpatient oncology team.  Neurosurgery was consulted and recommended use of a thoracolumbar sacral orthosis (TLSO) brace to help with pain due to metastatic disease.  Pain management was also consulted and recommended use of a Fentanyl patch.  Orthopedics saw her and recommended only x-rays.  No intervention was recommended otherwise.  The patient was using a rolling walker when admitted, which was her usual baseline.

No, the proposed inpatient admission was not medically necessary.

This patient was found to have extensive metastatic breast cancer and records clearly document that she had this at least two years.  None of the issues encountered during this admission were acute medical issues.  She had nausea/vomiting, but there is no documentation indicating that this was refractory to treatment in the ED.  She had extensive bony metastatic disease that had been present for an extended period of time.  She required no acute surgical intervention and she had no significant hemodynamic instability, active infection or oncologic emergency necessitating acute care inpatient admission.  The interventions taken during this admission (thoracolumbar sacral orthosis brace, specialist consults, treatment with pain medication) did not require acute care inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adenovirus

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This infant with no significant past medical history presented to the emergency department (ED) with complaints of a four day history of cough, runny nose, congestion, and a tactile fever. She was taken to the Pediatrician on the day of arrival. The patient received albuterol and Decadron without improvement. In the ED, the patient had a high temperature and high respiratory rate. She appeared to be pale and had a nasal discharge. The lung examination was significant for rhonchi and belly breathing. She was placed on oxygen via nasal cannula (NC). The rapid viral panel (RVP) was positive for adenovirus and respiratory syncytial virus (RSV). She was given intravenous (IV) fluids and IV Ceftriaxone. The patient was admitted to the pediatric intensive care unit (PICU) for further management. On the floor, the patient was weaned to room air. She tolerated that well. Oral (PO) feedings were continued. Albuterol was given every 4 hours (Q4H) and the patient was started on a five day course of prednisolone. Her symptoms improved after treatment and she was discharged. 

The patient's RSV and adenovirus was positive and the presentation to ED was concerning. There was RR (respiration rate) 60s and SpO2 (oxygen saturation) 80s. The ED physician appropriately did the High Flow nasal cannula, which indicated that patient was close to respiratory failure. The patient was also dehydrated. The patient at this point had poor pulmonary reserve and the viral burden is increased with 2 simultaneous viral infections. The patient improved in the PICU. On the floor, the patient was weaned to room air. She tolerated that well. PO feedings were continued. Albuterol was given Q4H and the patient was started on a five-day course of prednisolone. Her symptoms improved after treatment, and she was discharged.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.