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

Diagnosis: Diabetes, neuropathy, and Charcot foot deformity. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female. She suffers from diabetes, neuropathy, and Charcot foot deformity. She has had a history of several digital amputations. She developed a foot infection with malodor purulence and she was admitted. During her admission, she underwent vascular testing to assess her perfusion. Infectious disease was consulted for antibiotic management. She was administered IV (intravenous) antibiotics. Lab work was done as well to assess for sepsis. She was discharged home with follow-up with her primary and her podiatrist. 

Yes, the Inpatient admission was medically necessary. 

The patient's diabetic foot infection was not improving on outpatient therapy require hospitalization. This typically requires a workup with infectious disease input and antibiotics. Once this is improved (in this case two days post), the patient may be discharged to outpatient care. All the appropriate steps were taken here, and the inpatient admission was is in keeping with standard of care for diabetic foot infections. Delay in hospitalization can lead to amputation. 

Delay in care can lead to amputation of the foot. In diabetic foot infections, patients are neuropathic and cannot feel their foot. As such, pain is a poor indicator of clinical status. When practitioners evaluate the diabetic infection and see that it is not improving, this is an indication that there may be deeper infection this requires further workup in a hospital setting. This patient's presentation was not appropriate for an outpatient management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Hip Osteoarthritis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female. She has history of morbid obesity, BPPV (benign paroxysmal positional vertigo), CAD (coronary artery disease), HTN (hypertension), OSA (obstructive sleep apnea) (on CPAP [continuous positive airway pressure]), bilateral hip OA (osteoarthritis) and diabetes.

The patient presented for a right THR (total hip replacement). Her ASA (American Society of Anesthesiologists) score was 4. She underwent surgery.

The patient's post-surgical course was non-complicated. She was able to ambulate with PT (physical therapy). Her glucose was monitored, with Endocrinology making recommendations for insulin adjustment.

The patient was discharged.

Yes, the Inpatient admission was medically necessary.

The medical record demonstrates that this patient was at extremely high risk for an adverse event. She has several "active comorbidities." She was anesthesia ASA (American Society of Anesthesiologists) 4. This has significant connotation as a risk factor. Her surgical anesthesia time was 6 hours, with an EBL (estimated blood loss) of 500cc (cubic centimeters). These factors increase her risk of post-surgical complication.

The patient had drains placed, which required monitoring and eventual removal. She has diabetes, which required management by Endocrinology. Blood sugars were monitored and required changes in dosage of insulin. She was actively using CPAP (continuous positive airway pressure). Her physicians specifically reported the necessity for inpatient care due to complexity of medical condition.

Based upon MCG (Miliman Care Guidelines) definitions, the patient's condition did not fall within the Guidelines for Ambulatory. Therefore, the Inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness And Weight Loss (kidney disease)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient Admission was not medically necessary.

The patient is a male with hypertension, heart disease, peripheral vascular disease and chronic kidney disease stage IV with baseline near 3.1 mg/dL (milligrams per deciliter) to the hospital with fatigue. Renal function was found to be near baseline based on renal consultation with plan for outpatient nephrology follow up. TSH (thyroid stimulating hormone) was found to be depressed, and patient was diagnosed with possible subclinical hypothyroidism.

The patient could have been safely and effectively been managed at a lower level of care. Based on available data there was no documentation of cardiac arrhythmias of immediate concern, recurrent seizures encephalopathy, active bleeding, severe infection, unexplained syncope or hemodynamic instability. There was no documentation of uremic symptoms, respiratory findings, clinically significant metabolic abnormality or electrolyte abnormality that requires inpatient care. There was no documentation of Hypertension requiring inpatient care, urgent treatment of renal failure necessary on inpatient basis, or other condition, treatment, or monitoring requiring inpatient admission. The patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Bone fracture/break
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld the health plan determination.

This case describes a  patient who sustained a fall onto the right arm at home. The patient was initially seen at an outside hospital where a right humeral shaft fracture was diagnosed. The patient had a reduction in the emergency room at the outside Hospital and was placed into a Sarmiento fracture brace. The patient then presented to the current facility Emergency Department with increasing right arm pain associated with numbness and tingling in the right hand and fingers. The patient was then admitted for further work up and definitive orthopedic care. The patient underwent surgical intervention for open reduction and internal fixation of the right humerus fracture. The patient recovered well from the surgery with no compilations. She had an uneventful hospital stay and was deemed stable for discharge to home.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The rationale for this determination is based upon the provided medical records which document that this patient sustained a right humeral shaft fracture that was initially treated at an outside hospital. The patient sought treatment at the current Hospital and was admitted for more definitive orthopedic care. The records show that the patient had an associated radial nerve palsy on examination. The plan was for open reduction and internal fixation of the right humeral shaft fracture and radial nerve decompression. The care rendered in this case is consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Chang and colleagues in Hand Clinics in 2018. The medical necessity of the inpatient hospital stay, however, is not established in this case. More specifically, the patient remained hospitalized for four days prior to surgical intervention for this comminuted humeral shaft fracture associated with a radial nerve injury. The records do not provide justification of the medical necessity of the inpatient hospital care. The patient had stable vital signs and normal lab values  prior to surgery. The records do not provide justification for the inpatient hospital care rendered for this patient on these days prior to surgery. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Diarrhea

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is upheld.

This is a male patient with a history of pancreatic cancer who was receiving chemotherapy. The patient presented to the Emergency Room (ER) and reported having persistent diarrhea for a week. In the ER, the patient was afebrile and his vital signs were stable. The patient's initial vital signs on arrival were: Temperature 98.3, Heart Rate 98, Blood Pressure 128/80, and Respiratory Rate 20. On examination, there was no abdominal rebound or guarding. The patient was given intravenous (IV) hydration and potassium replacement for his low potassium of 3.2. The patient's stool tests were positive for Clostridium difficile and Cryptosporidium. The patient was treated with oral vancomycin and nitazoxanide, and the patient's diarrhea improved.

According to Milliman Care Guidelines (MCG) guideline for Gastroenterology (MG-GAS), the medical indications for hospital admission includes severe diarrhea that is associated with high fevers, intractable bloody diarrhea, altered mental status, severe dehydration hemodynamic instability, severe electrolyte abnormalities or acute renal failure. In this case, the patient did not have these conditions. The patient's renal function was stable. The patient had mild hypokalemia that resolved with supplementation. 

Based on the review of the medical record, this patient had an infectious diarrhea. The patient required stool testing and the treatment was with oral vancomycin and nitazoxanide. This could have been done with observation status. Intravenous hydration and potassium replacement could have been given in the ER. The patient remained hemodynamically stable and responded well to treatment. The patient did not meet the MCG guideline for Gastroenterology criteria for an acute care inpatient admission. Thus, the full hospital admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The insurer denied inpatient hospital admission.  The denial is upheld in whole.

The patient is a female with known history of gastroparesis and inability to tolerate jejunostomy (J) tube feeding, who has parenteral nutrition with prior history of sepsis related to central line-associated bloodstream infection (CLABSI), presented to emergency room (ER) for evaluation of abnormal lab work on routine blood work with blood glucose reported at more than 1000 and hemoglobin at 7.1.  She reported very labile blood sugars at home ranging from 60-1000 depending on whether total parenteral nutrition (TPN) was infusing (10 hours a day) or if it was off (14 hours a day).  When she presented to ER in her private vehicle, she was clinically and hemodynamically stable with no significant physical exam findings.  Her lab work revealed elevated anion gap at 21 with venous pH of 7.4 with partial pressure of carbon dioxide (paCO2) of 29.  Blood glucose was 66.  Beta Hydroxybutyrate level was high.  With likely starvation ketoacidosis, she was admitted to Intensive Care Unit (ICU) for further treatment.  During hospitalization, she received intravenous (IV) fluids, IV Tylenol, morphine and Zofran along with optimization of her TPN regimen in consultation with endocrine and dietary teams.  Her acidosis resolved quickly, and once her home TPN dosing was adjusted, she was discharged home in improved condition.

The health plan's determination is upheld in whole.

The requested health service of inpatient hospital admission is deemed not medically necessary for this patient.

The metabolic acidosis due to starvation ketosis was mild with normal pH, with the need for dextrose containing IV fluids for a short duration.  The patient could have managed at a lower level of care in order to monitor and treat her mild ketoacidosis.  An inpatient stay was not medically necessary in this case.

The patient may have been admitted to Intensive Care Unit (ICU), as they were checking q1 hour accuchecks.  This reviewer does not see the need for every (q) 1 hour accuchecks in this case, considering the patient's hypoglycemia was mild and she was being placed on dextrose containing IV fluids.  Mild ketoacidosis with normal pH, likely starvation related, needs short term monitoring (at the most 24-48 hour) and administration of intravenous fluids, which was correctly given to this patient.  Her a.m. labs showed resolution of her anion gap and acidosis. 

Therefore, inpatient hospital admission was not medically necessary, and the patient could have been appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory/Stroke.
Treatment: Home Health.
Issue: The medical necessity of the increased PCA Services 12 hours a day 7 days a week split shift for a total of 168 hours a week.
The health plan determination is upheld in whole.

The patient has a past medical history significant for cerebrovascular disease, hypothyroidism, psoriasis, dementia, impaired fasting glucose, small cell lung cancer, congestive heart failure, ataxic gait, difficulty walking, muscle weakness and history of urinary tract infections. Patient had a hospitalization, but the status appears stable subsequently.
The patient was assigned 7.5 hours per day 7 days week for a total of 52.5 hours per week. The patient was previously receiving 5 hours a day 7 days week for a total of 35 hours a week. Services were increased because the patient's functional ability went down.
The requested increase in PCA hours is not medically necessary for this patient. The service hours assigned are adequate to meet the patient's functional needs for activities of daily living (ADL) and Instrumental activities of daily living (IADL) . Additional service hours are not medically necessary. The Uniform Assessment System (UAS) did not support the need for nighttime hours.
The patient is a female with multiple medical problems as listed above. The question is whether the patient needs 24 hour day 7 days a week service to meet these functional needs as listed. According to the most recent UAS state New York performed. These functional needs can be met with a total of 52.5 hours a week.

The patient appears to have multiple neurological deficits along with weakness and difficulty with mobility requiring assistance with transfers and most ADLs and IADLs. The question is whether the patient can be left safely at night without an aid present. The caregiver lives with the patient and is an informal caregiver but states that  work shifts are somewhat variable and cannot be a consistent caregiver. The patient does not have any nocturnal needs which would require frequent turning, such as a sacral decubitus ulcer or other wound infection. The patient does have frequent urinary incontinence. From an overnight log it appears that the patient usually gets up about once at night usually in the early morning between 4 and 5:00 to use the bathroom. This requires the help of an aide or caregiver. There were no other services provided during those time periods that would require the use of an aide. The patient is frequently incontinent even during the day and does wear adult diapers during the day. Typically adult diapers are rated for 1 L of fluid and 8 hours. Additional services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart failure.
Treatment: Continued Inpatient Admission.
The insurer denied the Continued Inpatient Admission.
The denial is upheld. 


The patient is a female with a past medical history significant for hypertension (HTN), dyslipidemia, chronic kidney disease (CKD), diabetes mellitus (DM), irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), anemia, and systolic congestive heart failure (CHF). She presented to the Emergency Room with complaints of dyspnea and bilateral leg edema. The patient was found to have acute CHF exacerbation due to medication non-compliance. She was admitted for management of CHF.

The patient was started on intravenous (IV) Lasix for diuresis. Medical therapy for CHF and HTN control, as well as for DM and lipid control, was provided and adjusted. Proteinuria was noted, and the patient underwent a renal biopsy with findings consistent with diabetic kidney disease. Her symptoms had improved, and the patient was switched to oral Lasix (furosemide). The patient had an oxygen saturation of 96%. Over the next four days, the dose of valsartan was increased for better blood pressure (BP) control, and diuresis with oral Lasix was continued. Pulse oximetry remained normal. Renal function remained stable with a creatinine level of 2.8. The patient was discharged from the hospital with a plan for outpatient follow-up.

No, the proposed continue inpatient admission was not medically necessary.

The patient presented with an acute exacerbation of CHF and was appropriately admitted to the inpatient level of care and managed with IV diuretics. After five days of diuresis, the patient was hemodynamically stable with adequate oxygen saturation. She was transitioned to oral (PO) Lasix. Renal function remained stable. The patient underwent renal biopsy with no evidence of complications, bleeding, etc. A continued hospital stay implies that the patient requires hospital services that can only be provided in an acute inpatient setting. There is no documentation that the patient's clinical condition had warranted any services that could only have been provided in the acute hospital setting. Therefore, she did not require any further hospital stay, and further treatment could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left arm pain, swelling and rash
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female whose inpatient admission is under review. The patient
presented with two days of nausea, vomiting, and one day of left arm pain, swelling
and rash after receiving a shot. The patient had positive history of eczema,
hypertension (HTN), asthma, and bipolar disorder.

In the emergency room (ER), triage vitals revealed blood pressure (BP) 100/60,
temperature 37.4 C (99.3 F) (oral), pulse 118, respiratory rate 22, and oxygen
saturation (SpO2) 98%. The patient's cardiovascular system (CVS) was normal,
pulmonary was normal, and abdomen was normal. Extremities exam revealed left
arm firm, indurated and erythematous over the area where the patient received an
injection. The remainder of the arm was erythema/warm.

Labs revealed the following:
White blood cells (WBC): 10.50 (high)
Hemoglobin (HGB): 11.7 (low)
Hematocrit: 35.4 (low)
Platelets: 309
Sodium (Na): 138
Potassium (K): 4.1
Chloride (Cl): 105
Carbon dioxide (CO2): 26
Blood urea nitrogen (BUN): 18
Creatinine (Cr): 1.53 (high)

In the emergency room (ER), the patient was noted to have persistent tachycardia
and cellulitis. The patient was given intravenous (IV) antibiotics including
vancomycin (followed by ceftriaxone) and was admitted. The patient improved after
a few days and was discharged.

Yes, the proposed treatment is medically necessary.

The patient was admitted for cellulitis and persistent tachycardia. The health plan
treated this as an admission for renal failure, when cellulitis is clearly stated and
listed as the primary problems in the emergency room (ER) note and History and
physical (H/P). According to the Infectious Disease Society of America, intravenous
(IV) treatment and admission are indicated when there are systemic signs of
infection (elevated white blood cells [WBC] and tachycardia), as in this case. Failure
to treat such a patient can lead to loss of function, abscess, shock, or death. Thus,
the health plan did not act reasonably, with sound medical judgment and in the best
interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acromegaly
Treatment: Mycapssa 20MG Capsules
The insurer denied the Mycapssa 20MG Capsules.
The denial is overturned.

The patient is a male with acromegaly. He has undergone transsphenoidal surgery. He has tried Sandostatin LAR (long-acting release), but this has resulted in injection reactions with large bruises. He has tried and failed cabergoline. The request for Mycapssa is under review.

Yes, the requested treatment with Mycapssa is medically necessary.

This patient has tried and failed Sandostatin LAR (long-acting release). He has already undergone transphenoidal surgery. He has persistent acromegaly and requires treatment for his macroadenoma. Growth of his macroadenoma could cause vision loss. The formulary alternatives to Mycapssa are Somatuline and Somavert. Given this patient's injection site reactions to Sandostatin LAR (long-acting release), he can reasonably be expected to have the same injection site reactions to Somatuline, as both are injectable somatostatin analogs. Somavert is not a medically appropriate option in this patient, as it is a growth hormone receptor antagonist, and it does not reduce tumor volume. Mycapssa is an oral medication and does not require injection. Use of Mycapssa in this clinical situation is supported by the Mycapssa prescribing information. Without Mycapssa, this patient will be at risk for complications of untreated acromegaly, which include type 2 diabetes. Therefore, yes, the requested Mycapssa is medically necessary.

The requested Mycapssa is medically necessary in this clinical situation and was denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atopic Dermatitis.
Treatment:  Dupixent

The insurer denied Dupixent. The health plan's determination is upheld.

The patient is a female with severe atopic dermatitis (75% body surface area involvement). The patient has tried and failed topical 2.5% hydrocortisone, mometasone, 0.1% ointment, and 0.1% triamcinolone ointment.

Dupixent is not medically necessary for this patient. The patient has insufficient to no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors or standard, first-line oral medications such as Methotrexate, Azathioprine, or Cyclosporine, and/or Phototherapy. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical dermatology reviews, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis C.
Treatment: Ribavarin.
The insurer denied the Ribavarin.
The determination is upheld.


The patient has chronic Hepatitis C and cirrhosis with a history of decompensation complicated by esophageal varices and thrombocytopenia. He failed Zepatier for 12 weeks. The genotype was 1b. The viral load was 126,000 international units per milliliter (IU/mL). He has non-structural 5A (NS5A) resistance-associated variants including Y93 and L31 mutations (which confer possible resistance to Vosevi). The coverage is requested for ribavirin 1000 milligrams (mg) daily for 12 weeks (to be used with Vosevi) for the treatment of chronic Hepatitis C. 
The medical necessity of ribavirin is not supported based on the provided information. The patient has failed at least one direct-acting antiviral containing an NS5A and NS3/4 inhibitor (Zepatier). In such cases, according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), re-treatment is recommended with 12 weeks of Vosevi monotherapy [1]. This is based on the POLARIS-1 [Safety and Efficacy of Sofosbuvir/Velpatasvir/Voxilaprevir in Adults With Chronic hepatitis C virus (HCV) Infection Who Have Previously Received Treatment With Direct-Acting Antiviral Therapy] trial, in which patients who have failed an NS5A inhibitor experienced a 97% cure rate with 12 weeks of Vosevi [2]. NS5A resistance-associated variants, including multiple, have not demonstrated an impact in cure rates when using Vosevi in genotype 1 patients [3,4].