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

Diagnosis:  Acute Psychosis And Prolonged QTc (corrected QT) Interval.
Treatment:  Inpatient admission.

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

The patient is a male.  He has a past medical history significant for HIV (human immunodeficiency virus), diabetes mellitus, and schizophrenia.  He was admitted via ER (emergency room) for acute psychosis. 

The patient was started on haloperidol and lorazepam.  Patient had an ECG (electrocardiogram) done, which revealed prolonged QTc (corrected QT) interval at 524 ms (milliseconds).  His cardiac enzymes were normal.  The laboratory data was significant for elevated serum creatinine, suggestive of acute kidney injury. 

The patient was admitted to telemetry due to acute renal insufficiency, prolonged QTc (corrected QT) interval and risk of ventricular arrhythmia with the use of anti-psychotic medications.  The patient was seen by cardiology in consultation.  Serial ECGs (electrocardiogram) were done.  IV (intravenous) hydration was provided for treatment of acute kidney injury.  His QTc (corrected QT) interval segment on ECG (electrocardiogram) had subsequently improved, and the patient was transferred to psychiatry.

Yes, the Inpatient admission was medically necessary.

The patient presented for an acute psychotic episode, requiring sedative and anti-psychotic medications use.  His presentation and course were complicated by acute renal injury and ECG (electrocardiogram) abnormality of QTc (corrected QT) interval prolongation, which in combination with the use of anti-psychotic medications with QT prolongation potential, posed a high risk of ventricular arrhythmia, sudden cardiac death.  Given the presentation, ECG (electrocardiogram) abnormality, need for psychiatric medications, risk of ventricular arrhythmia, sudden cardiac death, it would be consistent with the current standard of care that this patient be managed in an inpatient setting.  Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Grave's disease, bronchial asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female, morbidly obese, with past medical history (PMH) significant for Graves' disease, bronchial asthma, and hypertension.  The patient came to the emergency department (ED) for intractable diarrhea and abdominal pain of two weeks duration. She was admitted. 

Prior to this admission, the patient was admitted to the hospital with crampy abdominal pain and diarrhea, and gastroenterology (GI) was consulted and recommended stool studies and colonoscopy.  However, the patient left the hospital against medical advice (AMA), stating that her diarrhea had improved, and she was feeling better. On reaching home, she started having similar episodes of crampy abdominal pain and diarrhea after meals, with three to four  bowel movements per day (BMS/day). The stools were brown and thick liquid in consistency, and no blood in the stools. She also complained of crampy abdominal pain in the lower abdomen, nine out of ten (9/10) in severity. 

On admission, the patient was hemodynamically stable and afebrile. Her physical examination was essentially unremarkable. Her complete blood count (CBC),comprehensive metabolic panel (CMP), and urine analysis (UA) were unremarkable. The diarrhea was attributed to food poisoning. The patient was made 'nothing by mouth' (NPO) and was started on intravenous (IV) fluids and loperamide for diarrhea. Stool studies were ordered to rule out (r/o) infection. The next morning, the patient was feeling better and was discharged home with and outpatient follow up.

No, the proposed acute level care for the management of the patient's condition was not appropriate or medically necessary. 

The patient was admitted with symptoms of lower abdominal pain and diarrhea, secondary to gastroenteritis. She was hemodynamically stable and afebrile. Her labs including complete blood count (CBC) and chem-panel were essentially unremarkable with no evidence of any electrolyte abnormality or renal dysfunction. The patient got better the next day and was able to tolerate a soft diet. Given this clinical scenario, the patient could have appropriately been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/metabolic/nutritional
Surgical Services  (All)

Diagnosis: Gynecomastia
Treatment: Removal of Excess Tissue in the Breast Area 
The insurer denied the Removal of Excess Tissue in the Breast Area. The health plan's determination is upheld. 

This male has bilateral gynecomastia. He has not had any regression over at least two years. He denies any tenderness. He suffers from low self-esteem and embarrassment due to his breast size. Mastectomies for gynecomastia are planned.

The Removal of Excess Tissue in the Breast Area (Gynecomastia) is not medically necessary for this patient. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved. The records in this case do not provide any evidence of a concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance and use of analgesics as needed are standard management approaches for this condition. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Home Health Care. 
The insurer denied personal care services 24 hours a day, 7 days a week split shift. 
The denial is overturned in whole.

The patient is a female with past medical history of diastolic heart failure, severe osteoarthritis of the knee, hypertension, hyperlipidemia, and anxiety who had been hospitalized with new onset seizures, aspiration pneumonia, hypomagnesemia, hypokalemia, and hypocalcemia requiring intubation with Intensive Care Unit (ICU) stay. During this hospitalization, the patient was diagnosed with new onset atrial fibrillation and was started on anticoagulation. There was a request for Personal Care Assistance (PCA) services and the patient underwent a screening tool over the phone which assessed patient at total assistance with tasks of ordinary housework and locomotion while maximal assistance with tasks of meal preparation, stairs, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, and bed mobility while limited assistance with task of eating. The subject under review is the medical necessity for increase in personal care services to 24 hours a day, 7 days a week (split shift).

The health plan's determination is overturned.

The requested personal care services 24 hours a day, 7 days a week (split shift) is medically necessary for this patient. The patient had documented chronic medical diagnoses with progression and subsequent hospitalization twice for severe conditions of seizure, aspiration, GI bleeding and Clostridium difficile infection with documented decline in functional status. The patient had two telephonic assessment tools performed which should not have been utilized to calculate patient's PCA service hours as patient has 24-hour care needs. The patient has unpredictable and unscheduled care needs over a continuum of time. The plan did partially approve 24-hour PCA services as live-in, not split-shift. As per palliative care letter and overnight logs of patient care needs, the patient requires assistance at least every 2-3 hours with turning and repositioning and/or toileting and incontinence cares. These overnight care needs would not allow a live-in PCA to obtain at least 5 hours of uninterrupted sleep. The increasing PCA services is not solely for safety and supervision by to assist the patient was safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's medical provider has documented medical necessity of increased PCA hours to 24 hours per day split shift. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Renal Failure.
Treatment: Home Health Care (HHC)
The insurer denied home care / personal care HHC - level 2 personal care services (PCA), per 15 minutes increase to 70 hours per week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of kidney failure status post kidney transplantation, legal blindness, coronary artery disease, osteoarthritis, osteoporosis, hypertension, diabetes mellitus type 2 on insulin, hypothyroidism, hepatitis B, bladder incontinence, atypical hemolytic uremic syndrome, and anemia of chronic disease who had been assigned PCA (personal care assistance) at 38 hours per week based on assessment performed via the telephone. At this assessment, the patient was assessed at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, phone use, stairs, and transportation. With tasks of bathing, dressing upper body/lower body, walking, locomotion, and transfer toilet, the patient was assessed at limited assistance while independent with tasks of personal hygiene, toilet use, bed mobility, and eating. The patient underwent renal transplantation and was hospitalized. There was a request to increase PCA services to 10 hours/day, 7 days/week.

The home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 70 hours per week is medically necessary for this patient.
The patient had a significant change in her functional status following a renal transplantation. The patient had a complex medication regimen with activity limitations necessitating increased PCA services. The medical necessity of this increase in PCA services was documented by her transplant physician. The patient had undergone a telephonic assessment tool  with noted need for increased assistance with meal preparation, ordinary housework, transportation, bathing, dressing lower body, and bed mobility. The patient does live with her son but does not have informal help for all of the hours outside of PCA assigned hours. Increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of  Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). Following her transplant, the patient has multiple follow-up appointments and need for follow-up laboratory evaluations requiring assistance with transportation to these follow-up appointments and laboratory tests. The assessment tool failed to calculate hours for these increased/frequent provider and laboratory tests. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Synovial sarcoma

Treatment: Image guided radiation therapy (IGRT) for soft tissue sarcoma

The insurer denied coverage for image guided radiation therapy (IGRT) for soft tissue sarcoma.

The denial is upheld. 

This is a female patient who has been diagnosed with synovial sarcoma of the left axilla.  The patient initially underwent surgical intervention and has been recently recommended for adjuvant radiotherapy. She underwent an ultrasound revealing a 4.8 centimeter heterogeneous mass to the left axilla. Fine-needle aspiration revealed spindle cell lesion with a moderately cellular specimen and bland spindle cells. The pathology revealed a synovial sarcoma with SS18-SSX2 fusion gene. The physician indicated the patient was doing well and does have a prior injury from dancing. She has had prior surgical intervention and has required multiple aspirations. She has been started on prophylactic antibiotics and has been left with residual numbness from surgical intervention. She was recommended to undergo Positron Emission Tomography/ Computed Tomography (PET/CT) scanning for staging. Additionally, it was recommended that she undergo adjuvant radiotherapy to the postoperative bed. 

Regarding the requested services, the documentation indicated this patient has been previously diagnosed with synovial sarcoma of the left axilla. The documentation indicated she has undergone surgical intervention has been recommended to undergo adjuvant radiotherapy. The documentation indicated the recommendation has been made for image guided radiation therapy for soft tissue sarcoma. The current literature indicates image guided radiation therapy is the process of frequent 2- and 3-dimension imaging during the course of radiation treatment used to direct radiation therapy. The referenced literature indicates further evidence-based approaches for margins selection greater percentage involvement are needed for standardized use of image guided radiation therapy (IGRT) practices. The National Comprehensive Cancer Network indicates when External Beam Radiation Therapy (EBRT) is used in a rare situation, sophisticated treatment with IGRT may be needed. The submitted documentation does not indicate the patient is in need of the requested specialized services. The documentation indicated she has been recommended to participate in radiation therapy. However, there is no indication that the patient will need the requested treatment

The health plan acted reasonably in denying IGRT.

The insurer's denial of image guided radiation therapy (IGRT) for soft tissue sarcoma is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a female with no past medical history who presented with right upper quadrant pain. She was found to have uncomplicated acute cholecystitis. She underwent an uneventful laparoscopic cholecystectomy and was admitted to the inpatient service. She was discharged to home one day after presentation. The issue is whether an inpatient stay was medically necessary.

The inpatient hospital admission was not medically necessary. This is a young female with simple acute cholecystitis who underwent an outpatient surgery. It has been well established that uncomplicated acute cholecystitis can be managed safely without an inpatient stay.
In a review on the subject, the authors state "Emergency abdominal surgery seems to be feasible on an ambulatory setting for non-complicated acute appendicitis, acute calculous cholecystitis and gallstone pancreatitis." InterQual requires ascending cholangitis for inpatient criteria for cholecystitis. This patient does not meet such criteria, as there is no evidence of cholangitis in this case. With the patient's presentation and course of events, an inpatient stay is not medically necessary. As mentioned, this is supported by data that ambulatory management of acute cholecystitis is possible and laparoscopic cholecystectomy is an outpatient procedure. The patient had no other medical problems, instability, or complications from the surgery warranting an inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient Hospital Stay. 
The denial is upheld in whole.

The patient is a female who was admitted to the hospital for cough, chest tightness and shortness of breath. The patient has history of asthma and human immunodeficiency virus (HIV). The patient was diagnosed with asthma exacerbation. The patient Peak flow was 350. The patient was treated with intravenous (IV) steroids and bronchodilators. The patient's condition improved gradually, and she was discharged home in stable condition. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. At initial presentation in the emergency room (ER), the patient did not have any significant fever and there was no evidence of active infection. the maximum temperature was 97.9. The patient was breathing at a rate 18 and the oxygen saturation was 95% on room air. There was no evidence of hypoxemia. The lung exam showed mild wheezing with no evidence of silent chest. There was no evidence of abnormally low peak flow. There was no evidence of pneumonia or pneumothorax on the chest X-ray. There was no evidence of cyanosis. The patient did not require prolonged invasive or non-invasive mechanical ventilation.

There is no evidence that she had any clinically significant arrhythmia on the telemetry monitor. The patient was hemodynamically very stable and was not requiring any pressor. The heart rate was overall clinically acceptable at 89. The blood pressure was also normal at 117/76. The patient mental status was normal.
The patient's laboratory results were all clinically acceptable. There was no significant electrolyte abnormality. She did not have any surgical indication that would necessitate her to stay in the hospital. The patient was tolerating substances orally (PO). There is no evidence that the patient failed treatment or showed evidence of deterioration while residing in a lower level of care status.

In summary, the patient did not meet Milliman criteria for admission. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peptic Ulcer
Treatment: Home Health Care
The health plan denied the request for an increase in CDPAP services (split-shift).
The health plan's determination is overturned.

The patient is a female with a past medical history of congenital hearing loss, nonverbal status, vascular dementia, protein-calorie malnutrition, hypertension, bowel incontinence, bladder incontinence, and transient ischemic attack (TIA) who was hospitalized with a bleeding peptic ulcer requiring an exploratory laparotomy with placement of jejunostomy tube (j-tube). There was a request for Consumer Directed Personal Assistance Program (CDPAP) services and the patient underwent an assessment tool over the telephone, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, bathing, personal hygiene, dressing lower body, transfer toilet, and toilet use while maximal assistance with tasks of stairs, shopping, transportation, dressing upper body, walking, locomotion, bed mobility, and eating. The assessment note stated the patient lives with her daughter and six others and has severely impaired cognitive skills with occasional ability to communicate with sign language. The patient was assigned CDPAP services 12 hours/day, 7 days/week to total 84 hours/week. The patient had a subsequent hospitalization due to complications from the prior surgery and a j-tube with abscess formation. The patient had another telephonic assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, equipment management, personal hygiene, dressing lower body, transfer toilet, toilet use, and eating while maximal assistance with transportation, bathing, dressing upper body, walking, locomotion, and bed mobility.

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

Yes. The patient has documented medical conditions of congenital deafness, vascular dementia, bladder incontinence, bowel incontinence, sacral ulcer, and a j-tube with decline in functional status following two prolonged hospitalizations (at which time the j-tube was placed). The patient requires turning and repositioning as well as incontinence cares overnight that would not allow a CDPAP five hours of uninterrupted sleep. Furthermore, the family and healthcare advocate indicate the patient's home would not be able to accommodate a live-in aide due to limited space in the home. The overnight logs document the patient's overnight care needs every 1-3 hours necessitating a split-shift CDPAP. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Breast Cancer.
Treatment: Radiation Therapy.
The health plan denied the requested radiation therapy. 
The health plan's determination is overturned.

This patient is a woman with metastatic breast carcinoma involving her lungs, bone, liver and intraabdominal ascites. She has had excellent responses to systemic therapies and now has liver only progressing metastases. She is not a surgical candidate and is not a candidate for localized external beam radiation such as SBRT (Stereotactic Body Radiation). SIRT (Selective Internal Radiation Therapy) radioembolization is recommended with Y-90 microspheres directed to the liver lesions to attempt control of her disease.
At issue is the medical necessity of the requested treatment.

I overturn in whole, the health plans determination of medical necessity.

Yes, the requested treatment of SIRT is considered medically necessary for this patient.
The recommended SIRT for this patient with metastatic breast carcinoma that is progressing in liver only and is not considered a candidate for surgery nor other localized radiation options, is medically appropriate and necessary for this patient, as this is her only option for treatment to extend her survival and quality of life. There are very good data published in peer reviewed journals [1-5] supporting the use of SIRT for liver metastases from primary breast carcinomas with minimal risk of side effects. These studies are not randomized trials but are very good single institution studies supporting the benefits of SIRT for breast metastatic disease involving the liver with no other sites of progressing disease. This requested SIRT for this patient should be approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vaginal Bleeding.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient had vaginal bleeding and presented to the emergency department.  Her exam was normal except for blood in the vagina.  Vital signs were normal.  Her hemoglobin was 7.2 and she was not pregnant.  She was admitted as an inpatient and received 2 units of packed red blood cells.  She was discharged.  Her hemoglobin at discharge was 8.7.  At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.

The patient had vaginal bleeding with anemia; however, an inpatient stay was not medically necessary.  She could have received treatment with her transfusion in the emergency department or under extended monitoring without the need for high-level inpatient monitoring.  She received most of her transfusion before admission.  She could have received her transfusion at a lower level of care.  She had no abnormal vital signs or cardiovascular instability.  She had a history of obesity; however, she had no other significant morbidities.  She had no lung, renal or hepatic damage.  Except for the anemia, the lab results were normal, and she was discharged less than 24 hours later.  She did not receive surgery or other treatments that would require admission.