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

Diagnosis:  Loss of Consciousness.
Treatment:  Full Hospital Admission.

The insurer denied full hospital admission.  The denial is upheld.

The patient is a male with a history of hypertension, 6th nerve palsy, and possible transient ischemic attack (TIA). He presented to the emergency room after a witnessed brief episode of loss of consciousness. The vital signs were unremarkable. He was awake and alert, appeared well and in no acute distress. Physical exam was normal. Except for a blood alcohol level of 72.5, laboratory studies were normal. The head computed tomography (CT) scan showed no acute intracranial changes, and the chest x-ray was normal. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with an antiplatelet agent and a statin. The next day the cardiologist evaluated the patient and concluded that the syncope was most likely related to alcohol. An echocardiogram was performed, which was non-contributory. The remainder of the stay was clinically uneventful, and the patient was discharged later in the day.

The requested full hospital admission was not medically necessary for this patient. 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 that required acute inpatient admission. There was no evidence of an acute coronary syndrome or an acute cerebrovascular event. There was no hemodynamic instability, mental status changes, or severe metabolic disarray. The likely etiology of the syncope was readily apparent. The services provided - cardiac monitoring, oral medications, consultation - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature and Milliman Care Guidelines (MCG) guidelines, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Claudication of the right leg
Treatment: Angiogram Outpatient Procedure (37220x 1, 37224 x1, 37226 x1, 37228 x1)
The insurer denied: Angiogram Outpatient Procedure (37220x 1, 
37224 x1, 37226 x1, 37228 x1)
The denial is Overturned

The patient is an adult male. As per the H&P (history and physical), this patient presented with severe claudication of the right leg. His symptoms impair his normal function. He has failed a trial of Pletal and other conservative measures. ABI (Ankle Brachial Index) is reduced at 0.85. CT (computed tomography) angiogram from last year demonstrated near occlusion of the right common and external iliac. The request was denied coverage by the health plan on the basis that the imaging did not confirm the presence of a blockage in the leg. The denial is being appealed.

The Angiogram Outpatient Procedure (37220x 1, 37224 x1, 37226 x1, 37228 x1) is medically necessary.

This patient presents with disabling claudication. His symptoms are well described in office notes from the vascular surgeon's office. He has failed a monitored conservative therapy trial that included Pletal and weight loss. His ABI (Ankle Brachial Index) is reduced at 0.85, and he had a CT (computed tomography) angiogram that demonstrated severe right iliac occlusive disease. Angiography with possible endovascular intervention is appropriate. The provider has requested approval of multiple codes: 37220x 1, 37224 x1, 37226 x1, 37228 x1. The actual billed codes will depend on what is done at the time of the procedure. Since the blockages and treatment cannot be 
known in advance of the angiogram, it is routine to request approval for multiple codes, representing the most likely interventions. Therefore, given the above, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic obstructive pulmonary disease (COPD), hypertension and peripheral vascular disease.
Treatment:  Personal Care Aide (PCA) 24 hours/day, 6 days/week, and Consumer Directed Personal Assistance Services (CDPAS) 24 hours/day, 1 day/week.

The insurer denied coverage for PCA 24 hours/day, 6 days/week, and CDPAS 24 hours/day, 1 day/week.  The denial is overturned.

This is an elderly patient with chronic medical problems including COPD, hypertension and peripheral vascular disease.  He lives alone in a private residence and requires portable oxygen to complete activities of daily living (ADL).  The insurer approved PCA 10 hours/day, 6 days/week, and CDPAS 10 hours/day, 1 day/week.  The request is for PCA 24 hours/day, 6 days/week, and CDPAS 24 hours/day, 1 day/week.

The recent Uniform Assessment System (UAS) report was reviewed.  The patient's cognition is described as moderately impaired.  He is totally dependent to maximal assistance for much of his Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  He reportedly requires maximal assistance for bathing, personal hygiene, upper body dressing, bed mobility, locomotion and toilet transfer.  He is reportedly totally dependent for lower body dressing and toilet use.  Extensive assistance is reportedly needed for eating.  The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel.  

The patient's cognitive and functional ability have significantly declined when compared to the prior UAS reports.  His cognitive and functional deficits are at a level or unpredictable as to require the requested PCA 24 hours per day, 6 days per week, and CDPAS 24 hours per day, 1 day per week (live-in).  Based on the enclosed documents reviewed (including the care logs and appeal letter), the patient's health and safety are more appropriately provided and maintained at home by the provision PCA 24 hours/day, 6 days/week and CDPAS 24 hours/day, 1 day per week (live-in).  

From a physical medicine and rehabilitation perspective, PCA 24 hours per day, 6 days per week, and CDPAS 24 hours per day, 1 day per week, are medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) 24 hours per day, 6 days per week, and consumer directed personal assistance services (CDPAS) 24 hours per day, 1 day per week, is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Memory issues.
Treatment: personal care aide level 2- 84 hours/week, 12 hours x 7 days.
The insurer denied personal care aide level 2- 84 hours/week, 12 hours x 7 days.
The determination is upheld.


This is a female patient with a medical history notable for memory loss. The patient is approved for 3.5 hours 4 days per week and 3.25 hours 1 day per week (17.25 hours per week) of level 2 personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
There were no letters of support or physician notes provided as part of this review. A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented times three with periods of forgetfulness. She was self-directing and able to make her needs known. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation and housework. She requires extensive assistance for finances, medications, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing. She requires limited assistance for dressing and toilet use. Other ADLs are independent. She is infrequently incontinent of urine. A task tool associated with the assessment recommended 15.76 hours per week to address her personal care needs. Compared to a prior assessment, she showed a modest decline in her functional status. At issue is the medical necessity of personal care aide level 2- 84 hours/week, 12 hours x 7 days.

The requested health service/treatment of personal care aide level 2- 84 hours/week, 12 hours x 7 days has not been demonstrated to be medically necessary for this patient.
The patient's UAS demonstrates that she needs assistance primarily with her IADLs but also with bathing. The task tool recommended 15.76 hours per week to address her needs, and she is currently approved for 17.25 hours per week. There was no evidence provided that the patient has any unmet personal care needs at her current level of service. There is, therefore, insufficient evidence for medical necessity for the requested increase.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Wegovy.
The health plan denied Wegovy. 
The denial is upheld.

The patient is an adult female with prediabetes, hyperlipidemia, hypertension, obstructive sleep apnea, and obesity with a body mass index of 38.16. The request for Wegovy is under review. The prior request was denied coverage by the health plan, because, "you have not been enrolled in a complete weight management program along with counseling and monitoring by your doctor's office for the past 3 months." The provider is appealing this determination.

This request is for Wegovy for the treatment of obesity. The prior request was denied coverage by the health plan, as the patient is not documented to have participated in a complete weight management program along with counseling and monitoring by the patient's doctor's office for the past 3 months. The Endocrine Society guidelines on the management of obesity recommend weight loss medications be considered as an adjunct to lifestyle changes for patients who have been unsuccessful with diet and exercise alone. This patient does not have a documented medical reason that would preclude involvement in a comprehensive weight management program. The medical documentation does not indicate that the patient has tried and failed lifestyle changes. Wegovy has risks, including nausea and vomiting. Therefore, no, the requested Wegovy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Syncytial Virus bronchiolitis.

Treatment: Inpatient hospital stay.

The insurer denied coverage for inpatient hospital stay.

The denial is overturned.

This is a male child, that was an infant at time of admission, who had a worsening nonproductive cough. He had nasal congestion and an upper respiratory infection for four days. His sibling was also sick and was diagnosed with Respiratory Syncytial Virus (RSV) infection. When his breathing became more labored, and he was not feeding well at the breast the mother brought him to the emergency room (ER). He was treated with intravenous  (IV) fluids and a chest X-ray was obtained. When his breathing was noted to be labored, he was transferred to a different hospital for further treatment and possible admission. 

In the ER he was noted to have increased work of breathing and increased nasal secretions. He was in respiratory distress with a respiratory rate of 96 and his pulse oximeter was low 90% on room air. On physical examination he had head bobbing with abdominal and intercostals retractions noted. On examination of the lungs, he was noted to have wheezing and rhonchi. He was placed on oxygen of 35% at 6 liters of flow and when his respiratory distress did not improve, he was found to need Positive end-expiratory pressure (PEEP) and oxygen via high flow nasal cannula (HFNC). He was noted to not be feeding well at the breast and IV fluids were increased for possible dehydration. A respiratory viral panel was positive for RSV. When his breathing failed to improve with treatment and he continued to require oxygen supplementation the decision was made to admit him to the hospital for ongoing treatment with oxygen via HFNC, PEEP and IV fluids with a diagnosis of RSV bronchiolitis.

The infant was treated appropriately in the ER for coughing, hypoxemia and increased work of breathing. His increased work of breathing and wheezing did not respond to treatment with nasal sprays and suctioning. The decision to admit with a diagnosis of bronchiolitis for continued treatment with IV fluids and oxygen was medically indicated and consistent with the standard of care for an infant, weeks old, with hypoxemia and respiratory distress with increased work of breathing. The child's young age and ongoing need for HFNC oxygen supplementation placed him at high risk for ongoing respiratory distress and respiratory failure.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical insufficiency
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a pregnant female at 21 weeks estimated gestational age who was admitted for cervical insufficiency. On exam, the patient was found to have cervical dilation of 2-3 centimeters with bulging membranes. The patient was taken to the operating room to undergo an amnioreduction and cerclage placement and was discharged in the afternoon on the following day.

Inpatient admission was not medically necessary. The patient was in the hospital for only about 23 hours, demonstrating that there was not a serious concern for intrauterine infection or bleeding complications. The patient did not undergo serial labs, repeated exams, fetal monitoring, or any other intervention that would have required the inpatient setting. She recovered from her surgery, and was discharged with outpatient follow-up. She was only in the hospital for one night. Up-To-Date, a common physician reference, explicitly states that most cerclages are placed as an outpatient. The inpatient stay was not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Pharmacy/Prescription Drugs- Ropinirole extended release (ER) 4 milligrams
The insurer denied Pharmacy/Prescription Drugs- Ropinirole extended release (ER) 4 milligrams.
The determination is overturned.

The patient has a medical history of Parkinson's disease who is requesting treatment with
ropinirole extended-release (ER). The drug was denied because the member has not tried and failed three formulary alternatives. At issue is the non-formulary medication, Ropinirole extended release (ER) 4 milligrams (mg).

The patient has tried and failed two formulary alternatives and is using a third formulary
alternative with incomplete control of the disease. The patient has tried and failed
carbidopa/levodopa extended release and amantadine. The records also demonstrate that the patient is currently being treated with a third formulary alternatives resailing. As a result, the member meets the plan's criteria because the drugs on the formulary have been ineffective for treatment of the patient's condition. Additionally, the patient has been stable on the requested drug for about 3 years and change in therapy would deteriorate the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Choking spell.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is an infant who was born full-term with known respiratory syncytial virus (RSV) positive who presented to the emergency department (ED) following a choking spell requiring back thrusts, was treated with nebulized saline and discharged home. Since returning home, the parents had noted retractions and observed another spell with apnea for about 15 seconds, face turning red, with "smaller spurts of breathing". He was not feeding as well and was pale. The family was suctioning with saline at home. The examination was significant for no acute distress, normal appearance, moist mucous membranes, congestion, regular heart rate and rhythm, clear lungs, no wheezing, benign abdomen, and a non-focal neurologic exam. He was treated with nebulized saline and deep suctioning. Subsequently, he was able to tolerate a five-ounce bottle without vomiting or distress. Pediatrics was consulted and arrangements were made for transfer for a pediatric admission for ongoing management of RSV bronchiolitis, RSV apnea, and a brief resolved unexplained event (BRUE).
He was admitted to the telemetry unit for continuous pulse oximetry and cardiorespiratory monitoring. He had no further spells. He was breathing comfortably throughout his stay with no fevers, tolerating his feedings. He was deemed stable for discharge. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary.

This patient with a known respiratory syncytial virus (RSV) infection, presented following several spells of no breathing for up to 15 seconds, red color change but no cyanosis, and cough and congestion secondary to RSV illness. While it was not unreasonable to monitor this infant in the hospital for ongoing spells versus resolution of illness, he was overall hemodynamically stable, considered to be lower risk based on the above description and his age, with no significant metabolic abnormalities, and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male child with a medical history significant for croup and a family history of asthma who presented to the emergency department (ED) with audible wheezing and rib pain. The review of systems included right upper quadrant abdominal pain for four days associated with fevers, no bowel movement for three days, poor oral intake, vomiting, and a non-productive cough for four days. Examination was significant for no acute distress, right lower lung rhonchi and rales, left-sided chest wall tenderness, and a benign abdomen. A chest x-ray revealed a right basilar infiltrate concerning for pneumonia, and kidney ureter bladder (KUB) revealed a non-obstructive bowel gas pattern with moderate stool burden within the descending colon. He was treated with acetaminophen, ibuprofen, one DuoNeb treatment, a normal saline bolus, and ceftriaxone 1 gram (gm). He was admitted for further management of right lower lobe pneumonia.
Admission orders included continued ceftriaxone every 12 hours, follow-up pending blood culture, anti-pyretics as needed, intravenous (IV) fluids at maintenance, pediatric diet for age, continuous pulse oximetry, and vital signs every four hours. He improved the next day with no tachypnea or retractions. His appetite improved and his intravenous (IV) fluids were decreased accordingly. He remained on parenteral antibiotics and half-maintenance IV fluids. He was eating, he passed stool with resolution of abdominal pain, and he was afebrile. He was deemed stable for discharge home. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary.
This young male child presented with poor oral intake, persistent cough with some chest pain, and audible wheezing at home. A chest x-ray revealed right-sided pneumonia. He was admitted for parenteral antibiotics and intravenous (IV) fluids. He did well and was discharged home upon resolution of difficulty breathing and belly pain. While it was not unreasonable to monitor this child in the hospital, providing IV antibiotics and IV hydration, he was overall hemodynamically stable with no evidence of impending respiratory failure, no significant metabolic abnormalities, and no serious underlying conditions. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Bleeding
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who was brought to the emergency room (ER) by Emergency Medical Services (EMS) for vaginal bleeding. The patient was noted to have a past history of vonWillibrand disease (Type I) and almost passed out at home per EMS. The chief complaint was postpartum vaginal bleeding. She remained stable with stable vital signs in the ER. They were considering giving Factor VIII versus Desmopressin (DDAVP) for therapy. She had two large bore IVs in place. 1 unit of blood was given. Hematology/Oncology (Heme/Onc) also saw the patient in consultation and noted the plan for the patient to undergo a transvaginal ultrasound to exclude retained products. The Gynecology (GYN) team saw the patient and noted no bleeding on the pad and no active bleeding from the cervix on exam. A transvaginal ultrasound (TVUS) was reviewed by the GYN team and felt not to be consistent with retained products of conception and a dilation and curettage (D&amp;C) was not planned. DDAVP was planned for twice per day administration to control bleeding. Overnight, the vital signs remained stable and the patient responded to therapy without any ongoing bleeding. A repeat pelvic exam noted no active bleeding or clots. The patient was discharged to home with followup in the outpatient setting. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of acute inpatient level of care for management of vaginal bleeding in the setting of known Type I vonWillibrand disease in the postpartum state with 1 unit packed cells, DDAVP and IV TXA with stable vital signs was not medically necessary.  There was no active bleeding. There was no evidence of active major hemorrhage, coagulopathy with active bleeding, gestational trophoblastic disease, pregnancy related bleeding, or severe anemia. The bleeding was noted to be stable and not acute resulting in abnormal vital signs or cardiovascular collapse. There was no hemodynamic instability or tachycardia. The patient had a normal pulse rate and was maintained with intravenous fluids (IVF) and a single unit of packed red blood cells. Her hemoglobin was noted to be stable from the prior discharge postpartum to the readmission for this admission. There was no severe anemia accompanied by altered mental state, chest pain, exertional dyspnea, or syncope. Thus, the patent would be expected to be managed at a lower level of care than inpatient in this case.