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

Diagnosis: Left sided weakness
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department with concerns for left facial swelling, left-sided weakness, left-sided numbness, and a headache. The majority of symptoms resolved prior to arrival. The pertinent history included migraine headaches, vertigo, hypertension, and asthma. The initial examination documented the patient as alert, oriented and with a National Institute of Health Stroke Scale (NIHSS) of 1.  Neurology consulted and had an impression of a possible complex migraine, less likely a stroke. Recommendations were to obtain a magnetic resonance imaging (MRI) scan of the brain. There were no new issues. At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care. 

The patient had a history of complex migraine headaches and presented with left facial swelling and left-sided weakness. The initial examination documented the patient as alert, oriented, and with a NIHSS of 1. The treatment included aspirin and additional diagnostic testing. A comprehensive evaluation was performed including a CT (computed tomography) scan of the head, CTA (computed tomography angiography) of the brain, MRI of the brain, and MRI of the C (cervical)-spine which were essentially unremarkable for an acute pathological process. Following observation care, the patient had no complaints and was deemed medically stable for discharge. There was no recurrence of neurologic symptoms and no other issues or complications were documented.

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Full Hospital Admission
The insurer denied the full hospital admission. 
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) with substernal chest pain. The chest pain happened at rest. It lasted for a few minutes and then resolved spontaneously. There were no associated symptoms. The patient did not have a headache or any other associated symptoms. The patient has history of hypertension. The patient was not compliant with his blood pressure (BP) medications prior to admission. His blood pressure (BP) was 239/129 -243/146. His heart rate (HR) was 97 beats per minute (BPM) and his oxygen saturation was 99 percent (%) and he was afebrile.
His high sensitivity troponin was 5.8 and his creatinine was 1.4. His electrocardiogram (ECG) revealed normal sinus rhythm with left ventricular hypertrophy. His chest x-ray (CXR) revealed clear lungs. The patient was administered intravenous (IV) Lopressor. His BP remained high. He received one more dose of Lopressor and also Amlodipine, Aspirin and Clonidine. His BP remained high. The patient was admitted to the hospital for further evaluation of chest pain. By the time he was admitted his BP was down to 145/76. His physical examination revealed no acute distress. His lungs had normal breath sounds with no wheezing and his heart was regular. His abdomen was soft and non-tender. He had no lower extremity (LE) no edema. His skin had hyper pigmentation, with more on his lower extremities.
The patient's condition was stable, His BP was on the high side. The patient was consulted by cardiology. Regarding the elevated BP, it was recommended to adjust his medications. Regarding the chest pain, an echocardiogram and serial troponins were recommended. His creatinine went down from 1.4 to 0.9. The patient underwent an exercise stress test by Bruce protocol and both stress test and nuclear perfusion test were negative for ischemia. The patient was discharged home on oral anti-hypertensive medications.

The requested health service/treatment of full hospital admission was not medically necessary for this patient. The patient presented with chest pain and very high blood pressure. The patient's blood pressure was managed mostly with oral medications and normalized in 24 hours. The patient did not have symptoms from his elevated blood pressure. The patient did not suffer from hypertensive emergency or urgency. The patient's elevated blood pressure was asymptomatic. The patient did not have end organ damage from his elevated BP. There were no headaches, neurologic deficits, congestive heart failure, pulmonary edema, myocardial infarction or other complications.  The patient's stress nuclear test was normal, and most likely, his chest pain was not cardiac. 
Based on the above, the patient did not have indications for an inpatient admission. 

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain.
Treatment: Inpatient hospital admission.

The insurer denied Inpatient hospital admission.  The health plan's determination is overturned. 

This patient is a female with a past medical history significant for cardiomyopathy, asthma, hypertension, and diabetes mellitus who was brought to the emergency department (ED) by Emergency Medical Services (EMS) for evaluation of numbness and tingling in the arms and legs, along with chest pain that started after receiving a cervical spine epidural injection (dexamethasone) for chronic radicular pain due to disc herniations. In the ED, the patient underwent neurologic imaging demonstrating no acute abnormalities. Cardiac troponin levels were elevated. She was started on intravenous (IV) heparin, and aspirin 325 milligrams (mg).

An electrocardiogram (ECG) demonstrated anterolateral infarct. She was admitted to telemetry service under an inpatient level of care for evaluation of non-ST elevation myocardial infarction (NSTEMI). Cardiology and Neurology services were consulted. An echocardiogram was performed showing low normal left ventricular ejection fraction (LVEF) with basal inferoseptal and inferior wall hypokinesis. Left heart catheterization was performed showing normal coronary arteries and the patient was discharged later that day after cardiac catheterization.

At issue is the medical necessity of Inpatient hospital admission.

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

The requested health service/treatment of Inpatient hospital admission was medically necessary for this patient.

Admission under inpatient level of care was medically appropriate, necessary, and in the best interest for the safety of this patient. The patient presented with chest pain, elevated cardiac troponin levels, abnormal ECG (electrocardiogram) findings and echocardiogram imaging abnormalities consistent with NSTEMI (non-ST elevation myocardial infarction). The patient's calculated HEART (History, ECG, Age, Risk Factors, Troponin) score was 7, indicative of high risk for short-term major adverse cardiac events. According to the well-validated HEART pathway, inpatient admission in this case would be recommended for close telemetry monitoring, initiation of medical therapy with antiplatelets and full anticoagulation, and urgent coronary angiogram to relieve ischemic symptoms and reduce the risk of myocardial infarction and death. (1, 2)

Furthermore, due to the patient's NSTEMI presentation, inpatient admission would be considered standard of care according to the American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department. (3)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis Suppurativa.
Treatment: Humira (citrate free (CF)) Pen 80 milligrams (mg)/0.8 milliliters (ml).
The insurer denied Humira (citrate free (CF)) Pen 80 mg/0.8 ml.
The health plan's determination is upheld.

The patient is a female with hidradenitis suppurative (HS), described as severe and refractory by her dermatology provider. The patient is reported to have tried and failed topical Clindamycin and Aklief, as well as oral Clindamycin and Doxycycline for this condition over the past few years. The patient previously had acne but was treated and cleared for that diagnosis a year prior using Accutane.
A clinic note described inflamed pustules and scattered abscesses throughout the buttocks and inner gluteal cleft, at that time, the patient was noted to have never received prescriptions for Aklief or Clindamycin but was taking Doxycycline (100 mg/day) and using Sodium Sulfacetamide/Sulfur wash. 

The requested health service/treatment of Humira (citrate free (CF)) Pen 80 mg/0.8 ml is not medically necessary. The patient has not demonstrated, and has not been documented, as a patient who has an extent and treatment history of hidradenitis suppurativa that requires Humira treatment out of medical necessity, and not merely preference and/or convenience. The patient has no documented treatment failure with, or true medical contraindication to, a full three-month course of an appropriately dosed oral antibiotic (such as Doxycycline or Minocycline dosed at 100 mg twice daily, based on the patient's weight) that is required by the health plan [1] for coverage of Humira. The staging of the patient's hidradenitis suppurativa (Hurley Staging II or III is moderate to severe hidradenitis suppurativa) has not yet been provided. Accordingly, the patient is not confirmed to be a medically appropriate candidate for Humira (Food and Drug Administration (FDA) approved for moderate to severe hidradenitis suppurativa in patients who do not respond to first-line therapies such as long-term oral and topical antibiotics), consistent with current medical literature reviews for Hidradenitis Suppurativa. [2-6]

The health plan's determination of medical necessity is upheld in a whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

Patient is an adult with a history of asthma who presented to the emergency department (ED) with complaints of shortness of breath (SOB) for 2 days.  The patient also had a cough productive of greenish sputum. She did not improve with inhalers at home so she came to ED. The patient was given intravenous (IV) steroids, bronchodilators via nebulizer and magnesium in the ED. She was subsequently admitted to hospital for Asthma exacerbation.

Vital  signs as per history and physical: Temperature 99.4 degrees F, Pulse 80, Respirations 18, Blood Pressure 160/100.  Oxygen saturation on room air was 98%. She was in no acute distress with normal heart sounds. Lungs were clear to auscultation. She was placed on bilevel positive airway pressure (BIPAP)  (with oxygen saturation 100% ) initially and switched to nasal canula subsequently.  She was alert and oriented to person, place and time.

Labs were within normal limits. Covid Negative. Influenza negative. Chest x-ray showed no acute infiltrates. A computed tomography angiogram (CTA) was done which was negative for pulmonary embolus.

Patient was continued on Duo Nebs, steroids and Montelukast after admission. She improved with treatment and decided to sign out against medical advice (AMA) the next day a few hours after admission.

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status (which could be for up to 48 hours) while diagnostic testing and treatment were initiated. 

The patient stayed in hospital for less than 24 hours and her exam at discharge was essentially unremarkable and did not need continued hospital stay.

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 Inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatitis
Treatment: inpatient hospital stay
The insurer denied the inpatient hospital stay. The health plan's determination is upheld. 

This is a female with type 2 diabetes mellitus, hypertension, hyperlipidemia, and gastritis who presented with abdominal pain associated with nausea and vomiting. Temperature 98.5 degrees Fahrenheit, heart rate 87, blood pressure 171/75, respiratory rate 20, O2 (oxygen) 98% (percent). Lipase was 42, and white blood cell count 15.6. A computed tomography (CT) of abdomen demonstrated acute non-complicated pancreatitis. The patient was started on intravenous fluids and pain control. She was started on ceftriaxone empirically. 

The inpatient hospital stay was not medically necessary. This patient presented with abdominal pain with nausea and vomiting and was diagnosed with acute uncomplicated pancreatitis. She was nothing by mouth (NPO) overnight and had quick resolution of her symptoms. Her diet was advanced. Her pain was controlled. She was hemodynamically stable. Her diabetes was managed with her home insulin regimen. She had leukocytosis and was diagnosed with a urinary tract infection. She did not have evidence of sepsis or altered mental status. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is a young child with a history of 2 previous admissions for  Respiratory syncytial virus (RSV) induced bronchiolitis. There is a family history of asthma. He had been sick for 2 days with wheezing and shortness of breath. His mother administered 2 puffs of albuterol with no improvement in his cough. She then administered two doses of albuterol via a nebulizer. When there was no improvement, she brought him to the emergency room (ER) for further treatment.

In the ER he was noted to have nasal congestion, rhinorrhea and wheezing. On physical examination he was noted to have intercostal and abdominal retractions. His pulse oximeter was 95% and he did not require oxygen supplementation. He was treated with steroids, 3 doses of Combivent and magnesium sulfate. A chest x-ray was obtained which showed a small area of atelectasis. He tested positive for the influenza A virus and was treated with Tamiflu. A blood test did show a low bicarbonate level of 16. The medical record indicated that his wheezing had improved after therapy. Following treatment in the ER the decision was made to admit him to the hospital for continued treatment with albuterol every 3 hours with a diagnosis of influenza A virus and asthma.  

The admitting note indicated that the child was not in distress and had no evidence of increased work of breathing and the albuterol was ordered to be administered in the hospital every 6 hours.

The insurer has denied the medical admission as being not medically necessary.

The patient was treated appropriately in the ER for coughing, wheezing and increased work of breathing. His increased work of breathing and wheezing did respond to treatment with 3 doses of DuoNeb, steroids and magnesium sulfate. The admitting note indicated that the child was not in distress and had only mild wheezing audible upon examination of the chest after treatment. The child did not require oxygen supplementation. The child could have been safely discharged with continuation of Tamiflu, steroids and albuterol every 6 hours by nebulizer in the home with a follow up visit with the pediatrician in 24-48 hours. The child was clinically stable after treatment and could have been safely discharged. 

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: Upheld

Diagnosis: Diabetes
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination of medical necessity.

The patient is a male with a past medical history (PMH) of diabetes mellitus type 2 (DM2), hyperlipidemia (HLPD), and alcohol use disorder who was admitted with complaints of (c/o) abnormal labs. Vital signs were unremarkable. Physical exam notable for awake, alert, and oriented to person, time, place, and situation (AAOx4), well-appearing, no apparent distress (NAD), Clinical Institute Withdrawal Assessment (CIWA) 3. Lab work was notable for a lactate of 5.3, glucose 267, aspartate aminotransferase (AST) 280, alanine aminotransferase (ALT) 155, potential hydrogen (pH) 7.35, and carbon dioxide (CO2) 18. Imaging studies included an ultrasound (US) of the abdomen which showed hepatic steatosis, a computed tomography (CT) scan of the chest showed no acute pathology. An electrocardiogram (EKG) showed left ventricular hypertrophy (LVH). The patient was diagnosed with metabolic acidosis, uncontrolled diabetes with hyperglycemia and treated with intravenous fluids (IVF), insulin, and electrolyte repletion. The patient was discharged against medical advice (AMA) the next day. What is at issue is the patient's inpatient level of care.

The hospital stay was not medically necessary at an inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) abnormal labs, including hyperglycemia, low bicarbonate, and increased anion gap, without any other significant complaints. The patient was hemodynamically stable, responded to insulin therapy, and there was no diabetic ketoacidosis (DKA), acute mental status change, end stage renal disease (ESRD), sepsis, acute cerebrovascular accident (CVA), acute myocardial infarction (MI) or significant complications, no obtundation, no hyperosmolar hyperglycemic state, or pH less than 7.2. In addition, the patient's electrolytes and metabolic acidosis improved with treatment in the ED. Hyperglycemic patients presenting to the ED with blood glucose less than (<) 600 can be appropriately managed at a lower level of care. Overall, this patient was treated with IVF, insulin, and electrolyte repletion, all of which could have been safely provided at a lower level of care.
Regarding the provided Milliman Care Guidelines (MCG) criteria for Diabetes, the patient did not have pH < 7.3 or bicarbonate < 15, hypotension, altered mental status (AMS), acute kidney injury (AKI), inability to maintain oral hydration, significant electrolyte abnormality, DKA, hyperglycemic hyperosmolar syndrome (HHS), hemodynamic instability, or severe dehydration.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ovulatory Dysfunction
Treatment: Stimulation cycle number (#) 16 with intra-uterine insemination (IUI) # 4, code S4035 Stimulated IUI.
The insurer denied the request for Stimulation cycle number # 16 with IUI # 4, code S4035 Stimulated IUI.
The health plan's determination is overturned.

The patient is a female with ovulatory dysfunction and no known male factor. She has completed 15 cycles of Gonadotropin timed intercourse and one to three cycles of Gonadotropin intrauterine insemination (IUI).

In the determination of medical necessity, the health plan did not act reasonably, with sound medical judgement, with the best interest of the patient in this clinical scenario.

This patient has had 15 cycles of ovulatory cycles with timed intercourse (thus fixing the ovulatory dysfunction during those specific cycles) thus adding an "unexplained" component to this patient's fertility diagnosis. IUI (intrauterine insemination) is a reasonable adjunct in fertility care for unexplained infertility. As to the medical necessity of the gonadotropins, when reading the clinical notes, it is evident that she has very resistant ovaries and gonadotropins have been used safely though have not resulted in pregnancy. Outcomes for pregnancy are higher with gonadotropin cycles and considering she had many (15) cycles without pregnancy, making Gonadotropin a reasonable medically necessary choice for an ovulation induction agent in an upcoming cycle. As to the medical necessity of the gonadotropins, when reading the clinical notes, it is evident that she has very resistant ovaries and Gonadotropins have been used safely though have not resulted in pregnancy. Outcomes for pregnancy are higher with gonadotropin cycles and considering she had had many (15) cycles without pregnancy, making Gonadotropin a reasonable medically necessary choice for an ovulation induction agent in an upcoming cycle.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myocardial infarction and tachycardia
Treatment: Personal Care Aide, (consumer direct) for A Total of 70 Hours per Week
The insurer denied: Personal Care Aide, (consumer direct) for A Total of 70 Hours per Week
The denial is upheld.

The patient is an adult female. Her medical conditions include seizure, low back pain, dizziness, depression, and knee pain. She was admitted to the hospital with myocardial infarction and tachycardia. Denial of personal care aide, (consumer direct) for a total of 70 hours per week is being appealed. The health plan approved 45 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed two months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, bathing, and lower body dressing; limited assistance with toileting; supervision with walking and locomotion; and independent with phone use, personal hygiene, upper body dressing, bed mobility, and eating. She has infrequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with managing finances and 
medications, bathing, and lower body dressing. A letter from the patient's provider notes the patient has a complex neurological condition and needs additional hours to help with her multiple conditions. A letter from another provider notes the patient has several medical conditions and needs an increase in home care.

The requested Personal Care Aide, (consumer direct) for A Total of 70 Hours per Week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of personal care aide, (consumer direct) for a total of 70 hours per week is being appealed. The health plan approved 45 hours per week.
This patient has several chronic conditions and was recently hospitalized with myocardial infarction and tachycardia. Uniform Assessment System (UAS) evaluation completed two months ago shows she needs assistance with meal preparation, housework, shopping, managing finances and medications, bathing, lower body dressing, and toileting. She does not require assistance with walking, locomotion, phone use, personal hygiene, upper body dressing, bed mobility, and eating. Appeal statements note the patient has multiple chronic conditions and needs additional assistance to manage her medical conditions. Personal care aide services are not indicated for disease management or supervision. This patient's need for assistance with ADLs (activities of daily living) is met by the approved personal care aide services 45 hours per week. The requested increase to 70 hours per week is not medically necessary.