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

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

The patient is an adult who was hospitalized. The patient had been seen in the Emergency Department (ED) 1 day prior with an arm rash and was given prednisone and Pepcid. On ED (emergency department) triage diaphoresis, flushing and tachypnea were noted. Initial heart rate (HR) was 171, and oxygen saturation (SpO2) was 98% on room air (RA). The initial physical examination does not describe stridor, angioedema, or wheezing. An update describes some posterior oropharyngeal swelling and red arm rash but no stridor or wheezing. Two doses of epinephrine were administered, and improvement was noted. The patient was admitted with the statement that the patient was still having very mild symptoms. The vital signs showed HR (heart rate) 91, SpO2 (Oxygen saturation) 98% on RA (room air), respiratory rate (RR) 20, and blood pressure (BP) 142/98. The physical examination at that time describes no swelling, angioedema, wheezing or hives. Labs showed mildly decreased potassium and carbon dioxide, otherwise normal. Arterial blood gas (ABG) was normal. The patient was given steroids, Pepcid, potassium, and Benadryl. No otolaryngology (ENT) or anesthesiology specialty evaluations were performed. 

This patient could have been treated in an observation setting. The patient responded quickly to ED treatment within 2 hours of arrival. No laryngeal edema, stridor, drooling was described, and the purported pharyngeal edema resolved by the third hour of ED treatment. No ENT evaluation was requested attesting to the lack of perceived airway compromise.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hypertension, osteoarthritis, and dementia
Treatment: 84 hours per week of personal care aide (PCA) services, 12 hours per day, 7 days per week
The insurer denied coverage for 84 hours per week of PCA services, 12 hours per day, 7 days per week.
The denial is modified.

This patient is elderly with chronic medical problems including hypertension, osteoarthritis, and dementia. She lives "with a roommate who is bed bound." The insurer approved personal care aide (PCA) for 49 hours/week. The request is for PCA 12 hours /day, 7 days/week for a total of 84 hours/week.

The recent Uniform Assessment System (UAS) assessment report was reviewed. The patient's cognition is described as moderately impaired. She is "self-directing and is able to make needs known. Member is able to activate an emergency response in the event of any emergency." She requires extensive assistance for lower body dressing, toilet transfers and ambulation. Limited assistance is needed for upper body dressing and toilet use. She is frequently incontinent of bladder and infrequently incontinent of bowel. She is at the supervision level for personal hygiene, bed mobility, and eating. Her cognitive skills and functional ability have declined when compared to the prior UAS report. 

The combination of the patient's declining cognitive status and functional ability support the medical necessity of increasing the PCA 10 hours/day, 7 days/week, totaling 70 hours per week. Her condition and functional needs are not at a level or unpredictable as to require the requested 84 hours per week of personal care aide (PCA) services, 12 hours per day, 7 days per week. 

This physician would also agree that the patient may require additional monitoring. However, safety monitoring under personal care services does not include monitoring an individual (e.g. with dementia) when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, her health and safety can be appropriately provided and maintained by the PCA services 10 hours/day, 7 days/week for a total of 70 hours/week. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. Medical Necessity is substantiated for 70 hours per week of PCA services, 10 hours per day, 7 days per week.

The insurer's denial of coverage for 84 hours per week of personal care aide (PCA) services, 12 hours per day, 7 days per week is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Home Care / Personal Care HHC (Home Health Care) - Level
2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week
The insurer denied Home Care / Personal Care HHC - Level
2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week.
The health plan's determination is overturned. 

The patient is a female with past medical history of hypothyroidism, hypertension, hyperlipidemia, urinary incontinence, dementia, coronary artery disease, atrial fibrillation, and osteoarthritis who had been assigned Home Care / Personal HHC - Level 2 Personal Care Services (PCS).

Home Care / Personal HHC - Level 2 Personal Care Services: 84 Hours per Week are medically necessary for this patient.
There is documentation from the patient's PCP (primary care provider) of worsening cognitive and physical functioning. The patient required extensive assistance with tasks of transfer toilet and toilet use and therefore has 24-hour care needs that span a continuum of time. The insurer failed to document a plan to meet these 24-hour care needs. Because the patient has 24-hour care needs, a time-based tasking tool should not have been utilized to calculate hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient would require assistance for all hours outside of informal help. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS services 84 hours/week are medically necessary for this patient. 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:  Abdominal Pain
Treatment: Inpatient Stay
The insurer denied the inpatient stay.  
The determination is upheld.

The patient is a female who presented to the hospital with symptoms of abdominal pain and nausea. She had recently undergone laparoscopic cholecystectomy.
She has an insignificant medical history. The emergency department (ED) evaluation identified normal vital signs (heart rate of 77 beats per minute and temperature of 99.1 Farenheit). The patient had abdominal tenderness in the right upper quadrant. Her white blood cell count (WBC) count was normal and potassium level was 5.9. Her liver enzymes showed normal transaminases with a normal bilirubin. A computed tomography (CT) scan showed post-surgical changes from the cholecystectomy. There was no significant fluid collection in the gallbladder fossa, a right adnexal lesion was thought to be a fibroid. Initial treatment included intravenous (IV) fluid, antiemetics and pain medications. 
The patient's pain complaints resolved without intervention. The patient had normal vital signs and tolerated a diet.

Based on the submitted clinical documentation, an inpatient stay  was not medically necessary for this patient. The patient was admitted to the hospital with abdominal pain and nausea. She was status post a recent laparoscopic cholecystectomy. Her vital signs were normal at presentation. Laboratory data showed normal transaminases and bilirubin. Imaging completed with CT did not identify an acute pathology. The vital signs and white blood cell count remained normal during the period of observation until discharge. Her symptoms of abdominal pain and nausea resolved within one day of presentation. 
An inpatient level of care was not medically necessary. The patient was clinically stable at the time of presentation and remained so during the period of overnight monitoring as supported by the corresponding medical records and progress notes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

The patient is a female with a one day history of abdominal pain who was admitted to the hospital. A computed tomography (CT) showed a 1.3 millimeter (mm) appendix with a fecalith. The patient's white blood cell count (WBC) was 17. She was taken to the operating room (OR)  where she had a single port appendectomy performed.

An inpatient stay was not medically necessary. The patient could have been treated a lower level of care.  
She was given intravenous (IV) hydration as well as antibiotics, Morphine and Motrin. She was taken to the operating room (OR) where she had a single port appendectomy performed and was found to have gangrenous, non-perforated appendicitis. She did well and was discharged.

This patient had a non-perforated appendicitis in which the literature supports safety in same day discharge.

In reference 1, 180 pediatric patients that were discharged from the hospital within 24 hours of a laparoscopic appendectomy were evaluated. The study found that same day discharge after a laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way.
In reference 2, this study found that same day discharge for laparoscopic uncomplicated appendectomy should be the new standard of care. This study found no differences in outcomes with the timing of discharge. There was a significantly lower cost of stay for patients discharged home the same day.
Finally, a nurse driven pathway can improve length of stay as shown in reference 3.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient who presented to the emergency department (ED) complaining of one day of intermittent, burning, left-sided chest pain that was exacerbated by eating. His medical history was remarkable for atrial fibrillation treated with catheter ablation, mitral valve replacement, hypertension and pre-diabetes. A prior cardiac catheterization showed normal coronary arteries. In the emergency department (ED) his blood pressure was 116/81 millimeters of mercury (mmHg) with a heart rate of 77 beats/minute. An electrocardiogram showed sinus rhythm without acute changes. His serum troponin level was normal. His N-terminal pro brain (or B-type) natriuretic peptide (BNP) level was 944 picograms per milliliter (pg/ml). His international normalized ratio (INR) was 3.68. A chest x-ray showed no acute pathology. The patient was treated with intravenous Pepcid and Maalox and was admitted to the hospital. His troponin level remained normal. He was seen by a cardiologist who opined that his chest pain was likely non-cardiac. Per the progress note, the patient was stable for discharge but insisted on having an echocardiogram prior to discharge. This showed a normal left ventricular systolic function and mild mitral regurgitation and he was discharged. The medical necessity for an inpatient admission is under review.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with atypical chest pain. He was hemodynamically stable, with normal serum troponin levels, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. While his INR was supratherapeutic he had no signs of active bleeding. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/ American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST) /Society for Academic Emergency Medicine (SAEM)/ Society of Cardiovascular Computed Tomography (SCCT)/ Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stones
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient was admitted for kidney stones. He was evaluated by urology and underwent cystoscopy with stent placement which was tolerated well. He was discharged in stable condition.

Inpatient admission was not medically necessary per evidence-based literature.

A systematic review and meta-analysis including 23 randomized controlled trials (2458 patients) found that outpatient therapy in addition of medical expulsive therapy (with alpha blocker) to ESWL (extracorporeal shock wave lithotripsy) in ambulatory settings in patients with renal or ureteral stones improved expulsion rates, reduced time to stone clearance, and reduced pain. [1]

Meta-analyses of randomized controlled studies have found that use of an alpha blocker as an outpatient is associated with shorter times to stone passage and lower risks of surgical intervention. [2]

A multisite prospective study of 2759 adult patients (mean age 41 years) with suspected nephrolithiasis found that most were discharged home from the emergency department, and only 9% (percent) required hospitalization. [3]

Analysis of a national database that included over 3.6 million visits to the emergency department for renal or ureteral stones found that 12% of patients required inpatient admission. [4]

His condition could have been treated safely under lower level of care and inpatient admission was not medically necessary.

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic migraines
Treatment is Ubrelvy 100 milligrams (mg) OR (oral) tablets
The insurer denied coverage for Ubrelvy 100 mg oral tablets.
The denial is overturned.

The patient has a diagnosis of chronic migraines. The request is for Ubrelvy 100 mg oral tablets.

The patient was seen for the diagnosis of chronic migraine. The physician noted that the patient was on topiramate and Namenda as well as fluoxetine for prevention and Ubrelvy as acute treatment. He noted that the Ubrelvy worked well. 

The patient was seen by another physician for chronic migraines. She noted that the patient failed propranolol, duloxetine, venlafaxine, Lyrica, Topamax, and Namenda. The patient also had a Botox injection. Ubrelvy is indicated and FDA (Food and Drug Administration) approved for the patient's condition and should continue with the medication for continuity of care.

"Acute treatment of migraine with ubrogepant compared with placebo led to significantly greater rates of pain freedom at 2 hours with both the 50-mg and 25-mg doses, and freedom from the most bothersome migraine-associated symptom at 2 hours only with the 50-mg dose." (Lipton et al., 2019).      

"A higher percentage of participants who received ubrogepant than of those who received placebo had freedom from pain and absence of the most bothersome symptom at 2 hours after the dose." (Dodick et al., 2019).

"Migraine is a chronic, often life-long neurologic disease that is characterized by recurrent and disabling attacks [14]. Migraine involves neurologic symptoms beyond headache, including vision changes, difficulty speaking and reading, increased emotionality, sensory hypersensitivity, gastrointestinal disturbances, neck discomfort, tiredness, yawning, food cravings, as well as the typical symptoms of phonophobia, photophobia, and nausea with or without vomiting [1, 5, 6]. Acute treatments are often used to shorten the attack and reduce the pain, migraine-related symptoms, and disability associated with individual attacks [7]. However, a subset of individuals with frequent attacks or disability may also require preventive treatment to reduce the overall frequency of attacks [79]. Successful preventive treatment has been reported to positively impact an individual's response to acute medication [10]. Conversely, failure to adequately respond to preventive treatment may be associated with a negative impact on acute treatment efficacy. Given the potential impact of preventive medication use on acute treatment efficacy, it is of clinical interest to evaluate the impact, if any, of prior or concomitant preventive medication use on the efficacy and safety of acute treatment options for migraine." (Blumenfeld et al., 2022)

Ubrelvy 100 milligrams (mg) oral tablets is considered medically necessary for this patient. 

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

The insurer's denial of coverage for Ubrelvy 100 milligrams (mg) OR (oral) tabs is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, post-traumatic stress disorder (PTSD) and osteoarthritis.
Treatment:  Personal care services (PCS) 8 hours per day, 7 days a week, for a total of 56 hours a week.
The insurer denied coverage for personal care services (PCS) 8 hours per day, 7 days a week, for a total of 56 hours a week. The denial is overturned.

This is an elderly male with chronic medical problems including hypertension, post-traumatic stress disorder (PTSD) and osteoarthritis. He is currently residing in a nursing facility due to needing assistance with activities of daily living (ADL). The insurer approved PCS 8 hours/day, 5 days/week. Under review is the request for increasing personal care services. According to the Uniform Assessment System (UAS) report the patient's cognition is described as "minimally impaired." He is able to "activate the 911 emergency system and PERS." He requires extensive assistance for bathing, personal hygiene, dressing and toilet transfer. He is frequently incontinent of bladder and infrequently incontinent of bowel. He is independent with eating, bed mobility and requires extensive assistance for ambulation. His ADL status and overall self-sufficiency have "declined" and "deteriorated," respectively over the past 90 days. The combination of his medical condition, functional impairments and progressive decline (e.g., functional mobility compared to the previous UAS report) and more recent hospitalization, support the medical necessity for increasing PCS to 8 hours/day, 7 days/week, totaling 56 hours a week; allowing the patient the ability to leave the nursing facility and return to living safely and independently at home.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. From a physical medicine and rehabilitation perspective, increasing PCS to 8 hours per day, 7 days a week, for a total of 56 hours a week is medically necessary.  

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

The insurer's denial of coverage for personal care services (PCS) 8 hours per day, 7 days a week, for a total of 56 hours a week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hand cellulitis.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

The patient has a past medical history significant for asthma, substance use disorder, bipolar disorder, and intravenous (IV) drug use who presented to the emergency department with complaints of left-hand pain and swelling at an IV drug injection site. 

Vitals on presentation included: Temperature 98.3 F (Fahrenheit) , BP (blood pressure) 103/64, Pulse 70, respiratory rate 18, oxygen saturation 99% on room air. Laboratory results included the following: WBC (white blood cell count) 7.89, HGB (hemoglobin) 11.7, HCT (hematocrit) 34.6, creatinine 0.75, glucose 113, and procalcitonin 0.16. 

The patient was started empirically on intravenous antibiotics (vancomycin and Ancef) for left hand cellulitis. An X-ray of the hand showed dorsal soft tissue swelling and no foreign body. She remained afebrile, hemodynamically stable, and clinically improved. The patient left the hospital against medical advice (AMA). 

The patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, the patient did meet criteria for observation level of management. She did not fulfill criteria for acute hospital admission. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.