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

Diagnosis: Abdominal/Stomach Pain.
Treatment: Inpatient hospital admission.
The health plan denied the inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a previously healthy female who presented to the emergency department (ED) with abdominal pain of 2-hours duration. At the time of presentation, the patient was without fever, her heart rate was 65 beats per minute (bpm), and her blood pressure was 122/81 millimeters of mercury (mmHg). She was tender in the epigastrium. The white blood cell (WBC) count was elevated at 14.6. The complete metabolic panel identified normal liver enzymes and bilirubin. An ultrasound and computed tomography (CT) scan showed gallstones, thickening of the gallbladder wall, and a normal caliber extrahepatic bile duct.

She was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. Surgery consultation was requested. She was treated with a laparoscopic cholecystectomy. The operative dictation recorded completion of the procedure without complication with findings of an inflamed gallbladder. The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, antibiotics, and antiemetics. The WBC count had normalized to 5.7. The diet was advanced, and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting.

The material submitted for review includes Milliman Care Guidelines (MCG) 26th edition Cholecystectomy by Laparoscopy.
MCG state that the goal level of care is observation, but that extended stay or inpatient care may be needed when there is:
1) Failure to achieve discharge status
2) Conversion to open procedure
3) Severe systemic infection that delays surgery
4) Severe infection postoperatively
5) Care for active comorbidities
6) Complications of procedure
7) Gallstone ileus

At issue is the medical necessity of the inpatient hospital admission.

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

The requested health service/treatment of hospital admission was not medically necessary for this patient. This patient was a female who presented to the ED on with abdominal pain of 2-hours duration. She was evaluated with labs, CT scan, and abdominal ultrasound. Based on the clinical history, labs, and imaging, she was diagnosed with cholecystitis. Surgery was performed without complication, and the patient was deemed suitable for discharge from the hospital on the first post-surgical day. Acute inpatient care was not medically necessary for this patient and this level of care was not supported by MCG 26th edition, Cholecystectomy by Laparoscopy.
The care provided during this period of time could have appropriately and reasonably been rendered with an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Legal blindness, macular degeneration, hallucinations, anxiety, chronic kidney disease, hypertension, degenerative joint disease, hypothyroidism, and atrial fibrillation. 
Treatment: Increase Consumer Directed Personal Assistance Service (CDPAS) to 7 Days per Week, 24 Hours per Day, Live-in, for a Total of 91 Hours per Week. 

The insurer denied: Increase Consumer Directed Personal Assistance Service (CDPAS) to 7 Days per Week, 24 Hours per Day, Live-in, for a Total of 91 Hours per Week. 

The denial is upheld. 

This elderly female has conditions including legal blindness, macular degeneration, hallucinations, anxiety, chronic kidney disease, hypertension, degenerative joint disease, hypothyroidism, and atrial fibrillation. She is appealing the denial of an increase in consumer directed personal assistance service (CDPAS) to seven days per week, 24 hours per day, live-in, for a total of 91 hours per week. The patient's family wants 24-hour care. The health plan approved consumer directed personal assistance service seven days per week, six hours per day, for a total of 42 hours per week. 

Uniform Assessment System evaluation performed recently showed the patient has infrequent needs with grooming, dressing, bathing, transferring, toileting, meal preparation, and feeding. Medical records show stable medication regiment. 

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 multiple medical conditions. She is appealing the denial of an increase in consumer directed personal assistance service (CDPAS) to seven days per week, 24 hours per day, live-in, for a total of 91 hours per week. The health plan approved consumer directed personal assistance service seven days per week, six hours per day, for a total of 42 hours per week. It is noted that Uniform Assessment System evaluation performed recently showed the patient has infrequent needs with grooming, dressing, bathing, transferring, toileting, meal preparation, and feeding. The information provided does not support that the patient has functional needs supporting the requested increase in consumer directed personal assistance 
service (CDPAS) to seven days per week, 24 hours per day, live-in, for a total of 91 hours per week. Based on all available information, the approved consumer directed personal assistance service seven days per week, six hours per day, for a total of 42 hours per week, is appropriate to meet this patient's needs for assistance with activities of daily living. The proposed consumer directed personal assistance service, live-in, is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhabdomyolysis, muscle weakness, myocardial infarction, pneumonia, atrial fibrillation, cognitive impairment, diabetes, malnutrition, hypertension, adjustment disorder, glaucoma, and hyperlipidemia.
Treatment: Personal Care Assistance Services, Level II 12 Hours Per Day, 7 Days Per Week for a Total of 84 Hours Per Week.
The insurer denied: Personal Care Assistance Services, Level II 12 Hours Per Day, 7 Days Per Week for a Total of 84 Hours Per Week.
The denial is overturned.

The requested Personal Care Assistance Services, Level II 12 Hours Per Day, 7 Days Per Week for a Total of 84 Hours Per Week is 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. Denial of personal care assistance services, 12 hours per day, 7 days per week for a total of 84 hours per week is being appealed. The health plan approved 56 hours per week. 

This patient has multiple chronic conditions with recent hospitalizations. Her current level of functioning is limited assistance with eating, extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toileting, and bed mobility, and maximum assistance with bathing and lower body dressing. She has bowel and bladder incontinence. Appeal statements indicate that the patient needs complete assistance with ADLs (activities of daily living) as well as repositioning in bed. A night log shows frequent assistance with repositioning and toileting. The information provided shows that this patient has significant limitations in functioning. Based on her current level of functioning, the approved personal care assistance services of 56 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The requested increase to 84 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease. 
Treatment: Remicade (J1745). 

The insurer denied: Remicade (J1745)
The denial is upheld

The patient is an adult male with moderate to severe Crohn's. He has failed prednisone, azathioprine and Imuran, and has been stable on Remicade for ten years. The plan preferred agent is Inflectra. The physician which is a medical doctor (MD) is requesting continuation of Remicade. Remicade was denied, as the patient has not failed Inflectra. 

The proposed Remicade is not medically necessary. 

Medical literature supports that patients treated with Remicade can safely be changed to an infliximab biosimilar. Therefore, there is not current medical literature to support that switching to a preferred formulary alternative would jeopardize the patient's clinical stability. Changing to Inflectra is clinically appropriate, accepted standard of care, and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a boy with a history of benign Rolandic epilepsy who presented with 2 back-to-back seizures. He was well until the day of presentation when he was sleeping and suddenly began to shake. He had tonic clonic movements of all 4 limbs and had urinary incontinence, frothing from his mouth, and his eyes rolled up. He was unresponsive during the episode, which lasted around 4 minutes. The emergency medical services team arrived and found him sleepy and unresponsive. In the ambulance he had a second seizure episode that involved his face. He was placed on an oxygen non-rebreather mask. The second seizure lasted for the whole ambulance ride which was approximately 10 minutes.

Inpatient hospital admission was medically necessary for this patient.

This is a young boy with a seizure disorder who presented with 2 back-to-back seizures. The second seizure lasted more than 10 minutes, and he had a prolonged post-ictal phase. Upon arrival to the emergency department, he was unresponsive and then vomited. He required inpatient admission for intravenous fluids, frequent neurology checks, and continuous monitoring with additional treatments as needed. He also required specialist consultation and an electroencephalogram (EEG).

The decision making at the time of admission for this patient was consistent with his young age, the occurrence of 2 back-to-back seizures, and the need for intensive monitoring and evaluation, intravenous fluids, and specialist care, which requires an inpatient setting.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with medical history of Ulcerative Colitis, prior Escherichia coli infection, irritable bowel syndrome, anxiety, and seizure disorder. He presented to the emergency department with diarrhea for 2 days, without abdominal pain, fever, chills, or hematochezia. Vital signs were unremarkable. Physical examination was notable for soft, nontender, nondistended abdomen. Labs showed unremarkable complete blood count, elevated potassium of 5.7, and elevated aspartate aminotransferase of 49. Gastrointestinal pathogen panel was negative, testing for ova and parasites, and stool culture were negative. Computed tomography scan of the abdomen and pelvis showed long-segment wall thickening of the descending colon and rectosigmoid colon with mild stranding of pericolonic fat and prominent adjacent lymph nodes, as well as submucosal fat deposition of the rectosigmoid colon, suggestive of acute on chronic Ulcerative Colitis. 
inpatient hospital admission is not medically necessary. The patient presented with diarrhea and imaging suggestive of Ulcerative Colitis disease flare. However, there was no complication such as intra-abdominal abscess, bowel perforation, toxic megacolon, peritonitis, severe bleeding, or sepsis, which would require the inpatient level of care. He was treated appropriately with mesalamine; neither biologic therapy nor colonoscopy were deemed necessary. Although his potassium was elevated, he did not have complications which required intervention. The interventions performed, including labs, monitoring, imaging, and Gastroenterology consultation, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned. 

The patient is an adult patient with a past medical history significant for polycystic ovarian syndrome and obesity who presented to the emergency department with complaints of worsening swelling on the back of the neck. Vitals on presentation included: Temperature 99.3 degrees Fahrenheit, Blood Pressure 138/83, Pulse 104, Respiratory Rate 18, Oxygen saturation 98% on room air. Laboratory values were notable for the following: White Blood Cells 15.0, Hemoglobin 15, Hematocrit 43.4, Glucose 129, Creatinine 1.08, Erythrocyte Sedimentation Rate 21, and C-Reactive Protein 7.7.

The patient was empirically started on intravenous antibiotics (ampicillin, doxycycline, and cefepime) for possible neck abscess. A Computed Tomography (CT) scan showed a collection in the posterior subcutaneous neck soft tissues. Otolaryngology (ENT) was consulted, and drainage of abscess was performed. Cultures grew Staphylococcus aureus. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Keflex) as an outpatient. 

According to documentation, the patient presented with a right neck cellulitis/abscess. The patient was afebrile, but tachycardic. Laboratory results were notable for leukocytosis. Surgery/ENT performed a drainage procedure. Based on above findings, the hospital admission was medically necessary for administration of intravenous antibiotics and surgical intervention.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient presented with abdominal pain and vomiting. She has had multiple previous admissions with the same symptoms. The urine toxicology was positive for tetrahydrocannabinol (THC). ln the emergency room (ER) she had a mild tachycardia and an elevated lactate level. At the time of admission she was afebrile, with stable vital signs, and was no longer tachycardic. The abdominal exam was benign. The renal function was normal. The lactate level improved with hydration. The leukocytosis was not as high as on previous admissions and was felt to be reactive. Her symptoms improved with the intravenous (IV) hydration and antiemetics. 

Clinical indications for admission for Vomiting (MCG M-370) include having a significant metabolic derangement such as ketoacidosis, hemodynamic instability, severe electrolyte abnormalities, severe pain, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had cyclic vomiting and was using marijuana. She required IV hydration and antiemetics. She improved with this treatment and the lactate level decreased. She could have been given the IV hydration and antiemetics in the ER with observation status. She did not meet Milliman Care Guidelines (MCG) criteria for admission for Vomiting. 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 the inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a medical history of gastroesophageal reflux disease (GERD), pancreatitis, hyperlipidemia, and prior alcohol abuse. He presented to the emergency department with epigastric pain, nausea, and vomiting for four days. His vital signs were notable for an elevated blood pressure of 148/96 millimeters of mercury (mmHg). The physical examination was notable for soft, nondistended abdomen. Lab results showed an elevated white blood cell count of 11.5 thousand per microliter (K/uL), low sodium of 134 millimoles per liter (mmol/L), elevated aspartate aminotransferase of 41 units per liter (U/L), elevated alanine aminotransferase of 87 U/L, and elevated alkaline phosphatase of 137 U/L. A computed tomography scan of the abdomen and pelvis showed mild infiltrative changes of the peripancreatic fat surrounding the pancreatic body and tail likely reflective of an acute interstitial pancreatitis; the pancreatic parenchyma enhanced relatively homogenously, and there was no peripancreatic collection. He was treated with intravenous ondansetron, Dilaudid, and fluids. He was made nil per os. His abdominal pain persisted. He was tolerating a diet well. Lab results showed an unremarkable complete blood count and comprehensive metabolic panel. He was discharged on oxycodone-acetaminophen. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary and the care provided could have been provided at a lower level of care.
The patient presented with abdominal pain, imaging, and lipase consistent with acute pancreatitis [1-3]. His pancreatitis was uncomplicated. There were no complications such as pancreatic necrosis, pseudocyst, or abscess [4-6]. No procedural interventions such as endoscopic ultrasound were necessary. He was appropriately treated with intravenous fluids, and his symptoms improved; the diet was advanced and discharge was then deemed appropriate. His liver enzymes were elevated, but there was no acute liver failure, choledocholithiasis, or other concerns [7]. The interventions performed, including labs, monitoring, imaging, and intravenous fluids with gradual advancement of diet, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a child who was having on and off fever for 8 days. The child was seen in the emergency room (ER) and discharged on the day prior to the admission date. The mother noted fever of 102.3 degrees at home and indicated that the child had decreased oral intake and activity level. There had been nasal congestion and coughing. The mother had also been coughing. The mother decided to bring the child back to the ER because the fever persisted.

In the ER she was noted to be breathing comfortably. The mother indicated that the child was urinating less than usually. On physical exam there was some evidence of dehydration and there was chest congestion upon examination of the lungs. Blood testing demonstrated mild hyponatremia with a serum sodium level of 133, an elevated C-reactive protein (CRP) of 22.9 and a low Bicarbonate (HCO3) level of 16. A chest x-ray, respiratory viral panel and electrocardiogram (EKG) were normal. The child was given a bolus of 200 cubic centimeters (cc) of intravenous (IV) normal saline and the decision was made to admit the child to the hospital with a diagnosis of dehydration.

The medical record documents that the patient had a mild degree of dehydration. This child received a bolus of normal saline in the ER which is the standard of care for the treatment of acute dehydration. There was no additional documentation of a repeat physical examination to document ongoing need for a second bolus of IV normal saline. When a child is being evaluated in the ER for dehydration it is the standard of care to treat with multiple IV boluses of normal saline and then to repeat the blood testing to evaluate the response to the IV fluid therapy to determine if the child is stable enough to be discharged home with continued oral rehydration.  The medical record does not support the medically necessity for 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 emergency admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyponatremia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a patient with a history of hypertension (HTN), mitral valve prolapse, and myomectomy who presented to the hospital with diarrhea after taking Amoxicillin for 6 days and nausea and vomiting for 2 days. She reported liquid, non-bloody stools with a foul odor and epigastric pain. She also reported a decreased appetite, feeling weak, off balance and periods of confusion. She denied fevers, chills, chest pain, shortness of breath, lightheadedness or a cough. Her lab results showed a sodium of 121, a potassium of 3.3 and a carbon dioxide (CO2) of 30.2. She was given 2 liters (L) of normal saline and oral potassium in the emergency room. A repeat sodium was 132 with a potassium of 3.4. A computed tomography (CT) scan of her abdomen and pelvis did not show any acute abnormalities. Nephrology was consulted for hyponatremia which they felt was secondary to hydrochlorothiazide (HCTZ) use in the setting of diarrhea. There was concern for her sodium over-correcting and the intravenous (IV) fluids were stopped with the recommendation for a repeat sodium at 2 PM, 8 PM and in the morning. The goal sodium correction was 4-6 milliequivalents (meq) within the first 24 hours. The next sodium level was 135 so she was given dextrose 5 percent in water (D5W) 250 cubic centimeters (cc) over one hour, Desmopressin (DDAVP) and placed on a fluid restriction. The sodium (Na) was 132 and she was given another 250 cc of D5W with a fall of the Na to 130. The Na was 132 and she was considered stable for discharge with lab and primary care physician (or provider) (PCP) follow up. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary based on the documentation provided. The patient presented with severe, symptomatic hyponatremia with a sodium of 121millieqivalents per liter (meq/L). Her sodium was then rapidly corrected to 132 meq/L within the same day as her presentation. She needed inpatient management to monitor her serum sodium concentration and safely bring it down and prevent further increases. Rapid correction of hyponatremia (greater than 6-8 meq/L with the first 24 hours) can lead to life-threatening central pontine myelinolysis. An inpatient admission was necessary to closely manage and monitor her serum sodium.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is overturned.

This is a male patient with an anterior crossbites on teeth 7 and 11. He presented with a skeletal Class I malocclusion with spacing in the maxilla and mandible. He is treatment planned for 24-30 months of orthodontics to address the spacing and crossbite. At issue is the medical necessity of braces and monthly visits.

This patient presented with anterior crossbites on teeth 7 and 11. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. Orthodontic treatment is medically necessary.