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

Diagnosis: Right axillary cellulitis/abscess

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with a benign past medical history who presented to the Emergency Department (ED) with complaints of right axillary cellulitis/abscess. The patient was treated with oral clindamycin the day prior to presentation. Vitals on presentation included a temperature of 98.3F, a blood pressure of 115/65, a pulse of 100, a respiratory rate of 20, and an oxygen saturation of 100% on room air. Laboratory results included a white blood cell (WBC) count of 13.1, a hemoglobin of 12.7, a hematocrit of 39, a creatinine of 0.6, a glucose of 126, an erythrocyte sedimentation rate (ESR) of 29, and a C-reactive protein (CRP) of 14.7.
The patient was empirically started on intravenous antibiotics (ceftriaxone and doxycycline). She underwent an incision and drainage without complications while in the ED. Cultures were negative. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue antibiotics as an outpatient.

According to the documentation, the patient was referred to the Emergency Room for an incision and drainage procedure of a small axillary abscess. Otherwise, the patient was afebrile and hemodynamically stable. Laboratory results were only notable for a mildly elevated WBC count.  The patient was capable of tolerating oral antibiotics and had no evidence for a systemic infection. 

Based on above findings, the patient met criteria for observation level of monitoring following an incision and drainage while in the Emergency Room. The procedure was uncomplicated and the patient did not meet criteria for hospital admission.

The prior determination of denial of inpatient admission has been upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Diagnosis: Lumbar Radiculopathy
 
Treatment: Physical Therapy, 2 visits 

The insurer denied the Physical Therapy, 2 visits. The denial was upheld.   

This is a female patient with a diagnosis of lumbar radiculopathy. It was reported that the patient had 3 falls in the past 6 months. She had complaints of pain that was described to be 6/10 in intensity. Her pain is located in her right buttock, right knee, and below the knee down to her ankle. The patient reported that she had difficulty and pain when performing her activities of daily living. The patient's Modified Oswestry Disability Index (MODI) decreased from 48% to 34%. The most current documentation reports that the patient was independent with a home exercise program in place.

According the referenced medical literature, physical therapy is supported for patients who have pain and/or functional deficits that have occurred as a result of injury or illness. Additionally, physical therapy is considered necessary if it is expected to result in significant therapeutic improvement over a clearly defined period of time and there must be documentation outlining quantifiable and obtainable treatment goals. The documentation indicated that the patient had been attending physical therapy since early 2019. The patient had completed 16 physical therapy treatments. The documentation indicated that the patient previously completed the goal of a home exercise program. However, there was no documentation of the patient's continued objective functional improvement with past physical therapy to support the need for ongoing visits.  The patient's pain level had remained the same since mid-2019. The patient should be well versed in a home exercise program.

Based on the above, the medical necessity for the Physical Therapy, 2 visits is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department on  dizziness, nausea, weakness, inability to eat, and gastrointestinal bleeding characterized by black-red diarrhea-like stool. She noted using ibuprofen a few times during the prior 2 weeks for treatment of headache. She had been consuming energy drinks, to which she attributed dizziness, diaphoresis, and palpitations. Vital signs were unremarkable.
Lab results were notable for a low hemoglobin of 7.7 grams per deciliter (g/dL). Fecal occult blood was positive. She was treated with a pantoprazole drip. She was transfused with 2 units of packed red blood cells. A Gastroenterology consultation recommended a proton pump inhibitor drip, following her labs, blood transfusion, nil per os (NPO), and an esophagogastroduodenoscopy. An esophagogastroduodenoscopy on  showed 3 superficial gastric ulcers without stigmata of bleeding (the largest was 15 millimeters (mm) in size and very deep), a medium-sized hiatal hernia, and a 40 mm polypoid lesion almost causing gastric outlet obstruction and covering the largest ulcer (this was biopsied); the recommendation was for oral proton pump inhibitor twice daily, clear liquid diet, and avoidance of nonsteroidal anti-inflammatory drugs. Biopsies of the gastric polyp ultimately showed a hyperplastic polyp, positive for focal intestinal metaplasia and negative for Helicobacter pylori. She was transferred to the intensive care unit.  A computed tomography scan of the abdomen and pelvis showed possible gastric antritis and possible colitis of the right colon. She was discharged  with a plan for Gastroenterology and Primary Care follow-up. The health plan's determination is upheld. The patient presented with symptomatic visible gastrointestinal bleeding and anemia. However, there was no sustained hypotension or tachycardia, and her hemoglobin responded to a blood transfusion. The patient was monitored closely, which was warranted as bleeding can be severe and sudden in onset; a proton pump inhibitor was initiated, which was also appropriate. The endoscopy revealed gastric ulcers, the likely source for the upper gastrointestinal bleeding, but it did not show active bleeding or a visible vessel. All of the measures that were undertaken, including monitoring, proton pump inhibitor therapy, serial lab monitoring, blood transfusion, Gastroenterology consultation, and endoscopy, could have been performed at a lower level of care without acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Urinary Tract Infection/UTI
Inpatient Hospital
The patient is male with a history of abnormal glucose. He presented to the emergency room with a several hour history of sharp left lower quadrant abdominal pain and nausea. The vital signs revealed a temperature of 100.2 and a heart rate of 104, but the blood pressure and oxygen saturation were normal. He was in no acute distress. Abdominal exam revealed mild left lower quadrant tenderness, but the bowel sounds were present. The chest x-ray and abdominal computed tomography (CT) scan were negative. The electrocardiogram (EKG) was non-contributory. The white blood cell (WBC) count was 20,000 and the glucose was 158. The urinalysis revealed 11-25 white blood cells (WBCs) per high power field with positive nitrites. The patient was admitted for further treatment and evaluation. The working diagnosis was pyelonephritis.
Upon admission, the patient was treated with empiric antibiotics. He was tolerating a diet. The urine culture grew out greater than (>)100,000 colonies of Escherichia (E) coli. Blood cultures were negative. The following day, he was feeling better and there was no tenderness on exam. The hospital course was clinically uneventful, and the patient was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. Other than the leukocytosis, there was no evidence otherwise for sepsis in that his vital signs were stable and there was no significant metabolic disarray. The CT scan was unremarkable. Within 24 hours he was feeling better and there was no further abdominal tenderness. There was no evidence that the patient required intravenous hydration, or that he failed appropriately aggressive outpatient or observation stay care. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  who received inpatient substance abuse rehabilitation treatment related to the use of alcohol and cannabis. Clinical records indicate problematic use of alcohol, marijuana, cocaine, Xanax, and codeine. The patient also reported feelings of paranoia that others were "out to get him." He was using 3.5 grams (g) of marijuana daily, drinking a half bottle of whiskey daily, and intermittently using codeine, Xanax, and cocaine. He described having blackouts earlier in the year. His clinical history was significant for two prior suicide attempts by overdose.
On admission, the patient denied any suicidal or homicidal ideation. There was no current self-injurious behavior on admission. Promethazine and codeine had been used rarely. Xanax similarly had been used intermittently. The primary substances of concern were therefore marijuana and alcohol. The patient had no auditory or visual hallucinations. Despite dimension of feelings of paranoia, later documentation stated "no psychotic symptoms noted." The health plan's determination is upheld.
The patient did not have a life-threatening medical condition or severe psychiatric crisis requiring immediate hospitalization. Alcohol was the substance with the greatest potential to cause harm to self or others. The patient clearly met criteria for an alcohol use disorder. The patient was not in remission from the relevant substance use disorder. He did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting. The patient did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting. He was not established in the clinical record as using in hazardous situations or in amounts or frequencies likely to imminently cause severe physical or emotional harm to self or others. Clinical documentation did not establish that the patient had interpersonal skill deficits. Clinical documentation did not establish that the patient had problems managing triggers for substance similar environment. The patient did have access to stable food and shelter.
Based on the responses, the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care is: Intensive Outpatient.
This patient needed help for alcohol and cannabis use disorders. He was reported to have already gone through detoxification at another facility. There were no unstable medical or psychiatric problems that required inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteomyelitis of the anterior tibial tubercle

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a male with past medical history significant for a right leg injury requiring sutures who presented to the Emergency Department with complaints of worsening erythema, pain, and swelling of the wound. Vitals on presentation included a temperature of 98.7F, a blood pressure of 108/64, a pulse of 78, a respiratory rate of 18, and an oxygen saturation of 100% on room air. Laboratory results included a white blood cell (WBC) count of 8.9, hemoglobin of 13.7, a hematocrit of 40.9, a creatinine of 0.8, and glucose of 93. This patient was admitted and started on intravenous antibiotics (ceftriaxone and doxycycline) for possible cellulitis of the right lower leg. An incision and drainage procedure were attempted, but was unsuccessful. No fluid was aspirated. A CT scan showed extensive cellulitis, areas of muscle necrosis, and edema. An MRI of the leg was positive for osteomyelitis of the anterior tibial tubercle. Infectious Diseases consulted and adjusted the antibiotic coverage. A bone biopsy was performed. Their clinical impression was chronic osteomyelitis and antibiotics were discontinued. 

According to the documentation, the patient presented with a cellulitis of his right lower leg following an injury to the site requiring sutures while on vacation. Otherwise, he was afebrile and hemodynamically stable with unremarkable laboratory findings, including a normal WBC count.  The patient had a localized infection with no evidence of systemic toxicity, no comorbid conditions, and no failure of outpatient intervention. Based on above findings, the patient was clinically stable for outpatient management. The patient did not meet criteria for acute inpatient admission.  

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

The patient is a male with past medical history of diabetes mellitus, hypertension, alcohol abuse, asthma and liver cirrhosis who was admitted to skilled nursing facility following hospitalization secondary to cerebrovascular accident (CVA) and acute respiratory failure.  

The health plan's determination is upheld.

The patient is a male who suffered a CVA. At time of admission to skilled nursing, he was dependent with bed mobility, transfers and unable to ambulate. In two months the patient was only able to progress to moderate assistance with bed mobility and transfers and both these functions remained at moderate assistance (MODA). In addition, while he did ambulate 10' maximum assistance (MAXA) this slow progress took over 2 months and MAXA (with assistance for weight shifting and walker management in the addition to a wheelchair follow) is not functional. Furthermore, wheelchair propulsion only progressed from dependent, to MAXA and the goal itself was discontinued. Hygiene/grooming also remained at MAXA from admission through discharge and toilet transfers remained dependent when goal was discontinued. Upper body dressing only improved from dependent to MAXA and remained MAXA and upper body bathing remained dependent when goal was discontinued. Review of documentation also showed that the patient was tolerating percutaneous endoscopic gastrostomy (PEG) tube feedings and was not requiring any skilled management of intravenous (IV) medications and/or extensive wound care. Therefore, as functional progress had not been made since admission over two months prior it was no longer appropriate nor medically necessary for this patient to continue at a skilled nursing level and his needs could be met at a lower level of care.

No, the requested health service of skilled nursing facility  is not medically necessary for this patient. The patient was admitted to skilled nursing but review of therapy documentation failed to show functional progress with the most progression being progress to MODA for transfers and bed mobility and this required over 2 months to achieve. Additionally, review of records fail to show skilled nursing needs such as IV medication or extensive wound care. It is not within recommended standards of care to remain at a skilled level of care when functional progress is unlikely to occur in a reasonable amount of time.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  with a significant past medical history, most notably for dementia and generalized deconditioning.  Live-in 7 days a week 24 hours a day consumer directed personal care was requested.  This was denied based upon medical necessity.  Patient is currently approved for 42 hours a week, 7 days a week  6 hours per day.  The health plan's determination is upheld.
Additional personal care services are not medically necessary in regards to the performance of activities of daily living (ADLs) or instrumental activities of daily living (IADLs).
This is a patient with a past medical history significant for coronary artery disease, cardiomyopathy, chronic obstructive pulmonary disease (COPD), hypertension, dementia, gastroesophageal reflux disease, headache and osteoarthritis.
Her health plan approved 42 hours a week.  She had a Uniform Assessment System (UAS) State of NY.  The testing assessment tool noted to the patient required an average of 3 hours a day 7 days a week for total of 21 hours a week to meet her needs including ADLs and IADLs.  The patient has memory issues, but she is able to ambulate independently in her residence.  She did have a hospitalization with a diagnosis of pneumonia and a brain lesion.  It was noted at that time that the patient was able to eat without help, she was able to use the bathroom with a little help, but she did need help with shopping, housework and preparing meals.  It was noted that the patient was safe to be left alone.  Personal care hours for safety monitoring and/or companionship are typically not considered medically necessary without the necessity of completing a specific task such as an ADL or IADL.  Based upon the documentation provided, the current level of personal care services are adequate to meet the patient's necessity for ADLs and IADLs.  Additional personal care services are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder -Severe- recurrent.
 
Treatment: Residential Mental Health Treatment

The insurer denied the Residential Mental Health Treatment. The denial was reversed.

This is a young female patient who was hospitalized for psychiatric treatment for her diagnosis of Major Depression Disorder- Severe. She has a past medical history of pain, reflex sympathetic dystrophy (RSD) and Lyme disease. She also had reports of emotional dysregulation, decreased motivation, anger, frustration, behavioral symptoms, increased physical aggression, threatening behavior with a knife. It was noted that the patient is failing academically and that she had been in custody and several foster homes in the past several months. She had 911 calls and police involvement, hospitalizations and Crisis treatment. A judge recommended residential treatment and psychiatric hospital staff upon her discharge.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. In this case, this patient had reports of increased aggression, downing Tylenol, which resulted in a psychiatric hospitalization, worsened mood and behavioral symptoms, had run away from a crisis treatment center, had 911 calls and police involvement, threatening behavior, and stopping medications. It was reported that she spent several weeks in Crisis Treatment and went absent without leave (AWOL) and was missing for several weeks. She reportedly refused therapy so intensive in home child and adolescent psychiatry services were ordered. She was hospitalized for "downing Tylenol" and police were called. It was reported that she had a psychotic break and threatened injury to a relative and had stopped her medications. It was reported that she was screaming at the top of her lungs, was regressing, and violated probation. She reportedly had charges of assault and threatening with weapons. She reportedly spent several days in the psychiatric hospital. 

As a result of her mood and behavioral symptoms, multiple ER and hospital treatments, harm to self and others, physical aggression, threatening behavior including with a weapon, and agitation, she was considered a danger to self and others and in need of continued 24 hour inpatient mental health residential treatment. 

Based on the above, the medical necessity for the residential mental health treatment is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Gastroesophageal Reflux Disease/GERD
Nursing Services (including Private Duty Nursing)

The patient is an female with multiple medical problems. She requests an increase in personal care service hours 4 hours per day 6 days a week, Monday through Saturday. The patient is asking for the additional hour due to being in a lot of pain and needing more assistance. The health plan has denied these services based upon medical necessity.

The health plan's determination is upheld. The Increase in Personal Care Worker (PCW) Service to Six (6) Days per Week, Four (4) Hours per Day (Monday-Saturday) is not medically necessary for this patient. There was no change in the patient's cognitive, functional status or overall self-sufficiency compared to the last assessment. The patient is able to walk, transfer and use a toilet set up. The patient is able to ambulate without the use of an assistive device. She is able to feed herself with meals that are prepared.
The patient was offered referral to home health agency for physical therapy services. The patient declined any services. The Uniform Assessment System (UAS) state of New York noted that the time allotted, 18 hours a week is sufficient to meet her medical needs.
The patient's medical condition did not significantly change from her previous evaluation. She is independent in most ADLs and is able to ambulate in her apartment. The patient is able to walk 5 blocks but only the reason she needs to rest is secondary knee pain. She is able to transfer and toilet independently. She is able to eat independently. There is no significant incontinence noted. The requested services are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage IV-V chronic kidney failure, prior stroke
Treatment: Personal care services, 24 hours/day, seven days/week, for a total of 91 hours/week 

The proposed treatment of personal care services, 24 hours/day, seven days/week, for a total of 91 hours/week is deemed medically necessary. 

This is a male with a history of multiple serious comorbid conditions including stage four to five chronic kidney failure, prior stroke, coronary artery disease, hypertension and diabetes mellitus. Due to the combined impairments from these medical conditions, he requires assistance with the majority of his activities of daily living (ADLs). Recent documentation from the patient's primary care physician indicates that the patient is frequent awake at night with nocturia and incontinence. Given his wife is also elderly and unable to assist with toileting, bed mobility, transfers, the currently approved schedule of eight hours a day, seven days a week is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in personal care services to 24 hours/day, seven days/week, for a total of 91 hours/week is deemed medically necessary for improved assistance with completion of the patient's ADLs.