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

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

The patient is a  man with a history of heart failure, seizure disorder, gastric bypass surgery, gastric ulcers, and alcohol abuse. He presented to the emergency department requesting detox from alcohol and Percocet. His Clinical Institute Withdrawal Assessment (CIWA) score on presentation was 4. He reported drinking 1 pint of liquor daily. He stated that he last used alcohol on the day of presentation. His longest period of sobriety was seven years. He stated that he usually used up to 40 milligrams (mg) of Percocet daily. He denied hallucinations, major depression, anxiety, mania, and suicidal or homicidal ideation. Vital signs showed temperature 98.2 Fahrenheit, heart rate 106, respiratory rate 20, and blood pressure 118/65. On physical exam, heart was regular, breath sounds were normal, abdomen was soft and nontender. There was no cranial nerve deficit reported. Labs showed white blood cell (WBC) 5.7, hemoglobin 6.4, platelets 347, sodium 137, potassium 4.2, and creatinine 0.81. The patient was admitted for microcytic anemia likely from malabsorption status post bariatric surgery, alcohol use disorder, and polysubstance abuse. 

The inpatient hospital admission was not medically necessary. The patient presented with anemia and request for detox, and while he needed further care, he was hemodynamically stable, had no evidence of active bleeding, was not hemodynamically unstable, and had a history of dysphagia and alcohol abuse that likely contributed to his anemia. The patient needed further care to evaluate his anemia and manage his detox. But this could have been provided at a lower level of care
Detox is routinely provided at a lower level of care and anemia is normally managed as an outpatient unless there's evidence of active bleeding, which was not demonstrated in this patient. It is correct that he declined a rectal exam but there was no documented rectal bleeding. Inpatient level of care is not needed for routine detoxification or for management of routine anemia in the absence of ischemia, active Gastrointestinal (GI) bleeding, or hemodynamic instability.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure-like activity
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of depression and post-traumatic stress disorder. She presented to the emergency ward with seizure-like activity. She was not post-ictal after the spell.

At presentation, the patient's neurological examination was normal, and CT (computed tomography) brain and cervical spine showed no acute findings.

No, the inpatient admission was not medically necessary.

At presentation, the patient had a normal neurological examination and diagnostic work-up. The patient had a single spell. The spell lacked emblematic features of generalized seizure such as tongue, bite incontinence or post-ictal confusion or lethargy. Given these factors, the diagnostic studies, clinical evaluation, treatment and monitoring could have safely and effectively been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leiomyoma, uterine fibroids, and postmenopausal bleeding.  
Treatment: Inpatient hospital admission.  

The insurer denied coverage for the inpatient hospital admission.  

The denial is overturned.  

This is a female patient with a past medical history of morbid obesity, type 2 diabetes mellitus, hypertension, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), chronic low back pain due to a bulging disc, anemia, and uterine fibroids.  The patient was admitted to the hospital for a planned supra-cervical abdominal hysterectomy with bilateral salpingo-oophorectomy due to a diagnosis of leiomyoma, uterine fibroids, and postmenopausal bleeding.  The patient tolerated the procedure well without any complications, and she was transferred to recovery.  Post-operatively, the treatment plan included pain management, wound care with dressing changes, advancing the diet as tolerated, encouraging ambulation and monitoring for any complications.  The patient was discharged in stable condition with outpatient instructions for medications, including aspirin for pain, and to follow up with the Gynecology clinic in two weeks.  

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient.  While laparoscopies are ambulatory procedures, laparotomies are not.  This patient underwent a laparotomy.  The standard of care is for patients who undergo an open procedure to stay in the hospital for 48-hours.  On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, and initiate a clear liquid diet.  On postoperative day 2, if the patient is passing flatus and tolerating regular diet, the patient is then discharged home.  

This patient was managed according to the guidelines and the standard of care, and the admission was medically necessary.  

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

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I skeletal relationship, severe maxillary and mandibular crowding, impacted maxillary canine and mandibular left second premolar. 
Treatment: Braces and Monthly Visit, Pre-service. 

The insurer denied the Braces and Monthly Visit, Pre-service. 
The denial is upheld. 

The patient is a female requesting dental benefits for orthodontic treatment and monthly visits.  The dental clinical summary states that the patient has a class I skeletal relationship, severe maxillary and mandibular crowding.  She has an impacted maxillary canine and mandibular left second premolar. 

No, the proposed treatment of orthodontic therapy and monthly visits are not medically necessary. 

Although the patient does exhibit some crowding on the right side of the maxillary arch, the patient is younger when the consultation and orthodontic records are made.  Given the age of the patient, it is possible that continued jaw growth and the exfoliation of her baby teeth can allow normal eruption of her adult teeth on the right side of her maxilla. The severity of the maxillary and mandibular crowding is not evidenced in the photos. 

The patient was eight months younger than the average age when eruption of these teeth typically occur when the consultation was performed. There is at least a minimum of eight months remaining for the normal eruption process to continue to unfold.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dehydration/Stomach Problems
Treatment: Inpatient Hospital
The health plan denied the inpatient admission. 
The health plan's determination is overturned.

The patient is a male who presented with fever and dehydration. He was well until the night prior to presentation when he developed a fever. He was drinking less than usual and had 5-6 episodes of loose stools. He also had decreased urine output and had temperatures from 102-103.5F at home. He was brought to the emergency department for care.
On physical examination he was febrile with a temperature of 38.1C. He was noted to look fatigued with mild pharyngeal erythema and a 2/6 systolic murmur. An oral fluid challenge was attempted in the emergency department, but he refused to drink. He was given two boluses of normal saline and was admitted for fever, dehydration, and a failed oral challenge.
In the hospital, he was given intravenous fluids. He continued to spike fevers to 100.8F. and 100.5F. and had limited oral intake. Over time he improved. He began to tolerate oral fluids and his urine output improved. He was felt to be stable for discharge to home with follow-up as an outpatient.
The hospitalization is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service of an inpatient stay was medically necessary for this patient.
This is a male who required hospitalization for continued intravenous fluids due to increased fluid requirement from his fever and loose stools and inadequate oral intake. In fact, he continued to refuse oral fluids even after receiving 2 boluses in the emergency department. Patients who present with increased fluid needs and cannot tolerate oral rehydration require inpatient admission to ensure adequate hydration and for close monitoring. [1]
The decision making at the time of admission for this patient was consistent with his age, the presence of fever, loose stools, and oral fluid refusal, and the need for ongoing intravenous fluids to maintain hydration status, along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld.

This patient is a male who presented to the hospital with complaint of abdominal pain. He had previously undergone laparoscopic appendectomy. He was clinically stable with normal vital signs at the time of emergency department (ED) presentation. He was found to have ventral hernias at two trocar sites used for appendectomy 17-days prior. He underwent primary tissue repair of two incisional hernia. The operative dictation describes the open primary tissue repair of two incisional hernias (left lower quadrant and umbilical port sites). The records document hemodynamic stability during the operation.
Following surgery, the patient was clinically stable, diet was tolerated, and pain medications were provided orally. He was discharged from the hospital following initial recovery.
The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole.

An inpatient stay was not medically necessary in this case. This patient presented to the ED and underwent ventral hernia repair. The operation and post-surgical recovery period was uncomplicated. The records support that inpatient care and treatment was not medically necessary. The patient was clinically stable at the time of presentation and remained so during surgery and during the early post-surgical recovery. He tolerated a diet and oral pain medications. He was discharged home following surgery. The care and treatment provided could have reasonably been provided at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/gastrointestinal. 
Inpatient hospital. 

Diagnosis: Hernia. 
Treatment: Inpatient stay. 

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

This is the case of a female with a history of an umbilical hernia who presented to the emergency department with a complaint of nausea, vomiting, and abdominal pain. Her umbilical hernia was found to be incarcerated and was unable to be reduced at the bedside. A computed tomography (CT) scan showed incarcerated fat in the hernia, but no bowel or other organs. She was admitted for urgent repair of the hernia, which was performed without complications. She was better and discharged to home. The issue is whether an inpatient admission was necessary in this case. 

The inpatient stay was not medically necessary. This patient had an incarcerated, fat-containing, umbilical hernia. While extremely painful, such a situation is not life-threatening and can be repaired with simple repair of the umbilical hernia in the same fashion as is done in the outpatient setting. An elective umbilical hernia repair is almost always an outpatient day surgery procedure. This case is no different surgically. Had there been bowel contained in the hernia that had been strangulated for some time, that would have been different. In this case, there was clear evidence both on the preoperative CT scan, as well as with the intraoperative findings, that there was no concern for bowel compromise. This patient had a very expected course for an emergent repair of an acutely incarcerated, fat-containing, umbilical hernia. In particular, she was taken emergently to the operating room and then discharged within 24 hours of the surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar Disorder
Treatment: Mental Health: Inpatient
The health plan denied the inpatient mental health stay (partial). The health plan's determination is upheld.

The patient is a young adult female, with a mood disorder best characterized as unspecified bipolar disorder and co-morbid borderline personality disorder. The patient was referred for emergency psychiatric services and admitted to inpatient level psychiatric services due to worsening depression and suicidal ideation. The symptoms of depression had occurred in the context of psychosocial stressors with no clear precipitant. The patient's worsening depression included a profound sense of hopelessness and low energy with morbid preoccupations of a delusional nature and auditory hallucinations. She was in outpatient mental health treatment with therapy and medications that included Vraylar, Lamictal and Klonopin at bedtime.
The patient had a previous history of psychiatric hospitalizations with the most recent with a manic episode, as well as self-harming behavior (cutting). There was a history of substance use disorder with alcohol and the patient had been sober and in remission.
Mental status examination revealed mood disturbance with depression and sad affect and anxiety. There were no other severe symptoms such as mania, thought disorder, severe cognitive impairment, or aggressive impulses. Her speech was clear and thought processing was linear with suicidal ideation in the context of anhedonia, guilt and low self-worth. Insight and judgment were fair with control of impulses in the context of anxious mood and depression including hopelessness and decreased concentration, energy and disturbed sleep.

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

No, the proposed treatment of Continued Inpatient Psychiatric/Mental Health Services was not medically necessary for this patient.
The health plan's determination of medical necessity is reasonable during the time interval under review. The patient's mood and affect were improved to the extent that the patient was more stable and no longer reporting active suicidal ideation, and the patient was participating in treatment with reasonable cooperation with staff including medication adherence and participation in her treatment plan. There were no remaining safety issues that would have required the structure and monitoring of an inpatient setting. These clinical features indicate that this patient could have later in the stay been effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Genitourinary/Kidney Disorder. 
Treatment:  UroLift procedure. 
The insurer denied UroLift procedure.  
The plan's determination is overturned. 

The patient is a male with  benign prostatic hyperplasia (BPH) who has tried tamsulosin. Cystoscopy demonstrated an obstructing prostate without a median lobe. The prostate volume was 50 cubic centimeter (cc) on palpation. He had the Urolift procedure. The subject under review is the medical necessity for the procedure.

The requested Urolift procedure is medically necessary for this patient.  He was symptomatic with BPH symptoms of slow stream and double void despite maximal titration of tamsulosin.  He was appropriate surgical candidate and did not have contraindications to surgery.

Per American Urological Association (AUA) Guidelines 15-15. PUL may be offered as an option for patients with lower urinary tract symptoms (LUTS) attributed to BPH provided prostate volume is less than (<) 80g and verified absence of an obstructive middle lobe. 
Developed in 2004, prostatic urethral lift (PUL) alters prostate anatomy without ablating tissue. PUL utilizes transprostatic suture implants delivered by a hand-held device through a cystoscope. The implants are composed of two, T-shaped bars with one on each side of a length of suture. They are spring loaded and deployed with one bar located outside the prostate capsule and the other within the prostatic urethral lumen. The tension between the two bars pulls the lumen of the prostatic urethra towards the capsule, compresses the prostate parenchyma, widens the prostatic urethral lumen, and improves symptoms. If properly placed, the urethral side of the implant epithelializes within 12 months. Histopathologic analysis of tissue obtained after PUL demonstrates a benign response to the implant, and no significant changes have been noted in PSA (Prostate-specific antigen).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Colesevelam Hydrochloride 3.75 GM Pak for medical necessity. 
The denial was upheld.

This patient is a female. She has a past medical history of biliary atresia status post-surgical repair (Kasai procedure), upper gastrointestinal (GI) bleed (UGIB) secondary to esophageal varices, status/post (s/p) endoscopic variceal ligation (EVL) times (x) 3. She is suffering from pruritus and portal hypertension.
At issue is the medical necessity of Colesevelam Hydrochloride 3.75 GM Pak.
The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Colesevelam Hydrochloride 3.75 GM Pak is not medically necessary for this patient.
When treating pediatric patients with pruritus, the use of Colesevelam Hydrochloride 3.75 GM Pak is not well established nor supported by adequate scientific evidence. According to Kuiper, Edith MM, et al: "This trial shows that colesevelam significantly lowers serum bile acid levels in cholestatic individuals with pruritus but is not more effective than a placebo in alleviating pruritus." The available literature does not allow a well-supported conclusion regarding the safety and efficacy of Colesevelam Hydrochloride in treating pediatric cholestatic pruritus. Therefore, the requested health service is not consistent with the generally accepted practices and is not proven to be medically beneficial.
Therefore, the medical necessity cannot be established for Colesevelam Hydrochloride 3.75 GM Pak for this patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's disease, Hypertension, Diabetes, Mellitus, Depression and Anxiety. 
Treatment: Increase Consumer Directed Personal Assistance (CDPAP) Services For The Total Amount of 49 Hours A Week. 

The insurer denied the Increase Consumer Directed Personal Assistance (CDPAP) Services For The Total Amount of 49 Hours A Week. 

The denial is partially overturned. 

The patient is a male with a history of Alzheimer's disease, Hypertension, Diabetes Mellitus, Depression and Anxiety. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 49 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support. 

Yes, in part. The requested 49 hours/week Personal Assistance Services is deemed medically necessary, in part. Specifically, 42 hours/week of personal assistance services are medically necessary.

The patient is a male with a history of Alzheimer's disease, Hypertension, Diabetes Mellitus, Depression and Anxiety. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities. An assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that 42 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. 

Specifically, the assessment revealed that the patient has sustained no recent falls, had no recent ER (emergency room) visits or hospitalizations. Furthermore, the patient's abilities to perform physical functioning stayed the same for dressing upper and lower body, walking, bathing, transfer toilet, eating, meal preparation and ordinary housework compared to his abilities when assessment during the prior Health Assessment Report. 

There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. 

Given that the assessment revealed that the patient needs 42 hours per week, the health plan's approved plan of 35.5 hours/week is not sufficient to meet the patient's needs. Also, given the above, 49 hours/week is in excess of the patient's needs. Therefore, 42 hours/week of consumer directed personal assistance program services are medically necessary. 

As per above, 42 hours/week of consumer directed personal assistance program services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Braces. 

The insurer denied the braces. 
The denial is overturned. 

The patient is a male requesting orthodontic benefits. 

Yes, the braces are medically necessary. 

The patient has a severe overjet, meaning his upper front teeth stick out severely. His overjet is more than 9 mm (millimeters) with incompetent lip closure and speech difficulties. This is an "automatic qualifier' for benefits according to the handicapping index scale. The braces are, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; Abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a past medical history significant for diabetes and gastroparesis. He who presented to the ED (emergency department) with complaints of abdominal pain, nausea and vomiting. The patient also complained of non-exertional chest pain.

The patient was hemodynamically stable. ECG (electrocardiogram) revealed normal sinus rhythm with non-specific T-wave changes. Cardiac troponins were negative. He was treated with antacids and Reglan. He was admitted to telemetry to rule out ACS (acute coronary syndrome). The patient signed out against medical advice and left the hospital the same day.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of abdominal pain, nausea and atypical chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  Based on the clinical information provided in the record submitted for review, the presentation does not support medical necessity for this admission. The care required could have been provided at an observational level of care.