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

Diagnosis: Angina
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This is a case of an adult with a known history of coronary artery disease who presented to the hospital for elective cardiac catheterization after complaining of recurrent typical angina. The past medical history was significant for hypertension and diabetes mellitus. Cardiac catheterization was performed utilizing a radial artery approach. Proximal left anterior descending disease was noted at the bifurcation of the left main. Percutaneous intervention with atherectomy was successfully performed. The patient noted chest pain post-procedure and was treated with intravenous nitroglycerin. Chest pain persisted and intravenous morphine was administered. The patient was found to be hypotensive following treatment (blood pressure 62/47). The patient responded to intravenous fluids and cessation of nitroglycerin. Given the hypotension following a high-risk intervention, the patient was admitted to the hospital for monitoring and treatment. Serum troponin levels rose from <0.01 to 0.18 to 5.56 to 6.54 ng/ml (nanograms/milliliter) over the course of 36 hours. An echocardiogram was performed and revealed an LVEF (left ventricular ejection fraction) of 66% without wall motion abnormalities. The patient was treated medically until the cardiac enzyme levels stabilized. 

Several investigators have studied the safety and cost savings surrounding same-day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. Current expert consensus from The Society for Cardiovascular Angiography and Interventions supports additional monitoring and treatment in the inpatient setting following a complicated initial 23-hour observation period. 

This patient presented with typical angina. There was a history of coronary disease and previous percutaneous coronary intervention. The patient's pretest probability of coronary artery disease-related symptoms was high. The patient underwent cardiac catheterization and stent placement and atherectomy to the proximal LAD (left anterior descending artery) at the bifurcation of the LAD/LCx (left circumflex) arteries. This patient developed chest pain, hypotension, and troponin rise post-procedure and required inpatient monitoring and treatment. In conclusion, the inpatient admission was medically necessary.  

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epstein-Barr virus (EBV)
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This patient had evidence of pharyngitis from a proven Epstein-Barr virus (EBV) infection, but he had no objective evidence of dehydration. BUN (blood urea nitrogen) and creatinine were normal. There is no urinalysis report, in which a specific gravity could help assess the degree of dehydration. He had normal vital signs and is consistently described in the emergency department (ED) and the admission notes as well appearing and non-toxic. His throat exam did not reveal evidence of obstruction, tonsillar abscess, trismus, drooling, or deviation of the uvula from the midline, that would interfere with oral intake. There is no documentation of a trial of oral feedings and the medical justification for admission is stated as the mother's apprehension about his inability to take food and drink orally. In fact, it is documented that he responded to a normal saline bolus with resolution of tachycardia and had a wet diaper following the bolus. Management could have been a several hour trial of oral intake in the emergency room.

Even if we assess this patient as having mild dehydration, per current literature on management of dehydration in children, and using the CHOP (Children's Hospital of Philadelphia) pathway, a trial of oral rehydration following a bolus of IV (intravenous) fluids should be done, especially as there were no ongoing losses (there was no ongoing vomiting or diarrhea). This could have been tried during a further period of observation and treatment on the ED for at least several more hours.

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

This patient is an adult male with history of chronic obstructive pulmonary disease (COPD), throat cancer status post-surgical resection, tracheostomy, radiation treatments, and chemotherapy. The patient had tracheostomy removed.

He presented to the Emergency Department with increasing shortness of breath (SOB) and some throat swelling. On presentation vital signs were Temperature 97.6-degree F (Fahrenheit), Heart Rate 71, Respirations 20 and blood pressure (BP) 138/90 mm Hg (millimeters of mercury). Oxygen saturation was 96 % on room air. The patient was in no distress. The tracheostomy site was clean, and his lungs were clear. CVS (cardiovascular system) S (sinus rhythm)1 S2 N (normal). He was alert, oriented and ambulatory. White blood cells (WBC) 7.8K (thousand), Hb (hemoglobin) 12. A computerized tomography of the neck revealed a hypopharyngeal mass.

This patient did not need acute hospitalization. He could have been placed in Observation status while awaiting a bed. He was hemodynamically stable and there was no acute airway issue other than one episode which improved with Racemic epinephrine. 

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain
Treatment: Lumbar Spine Magnetic Resonance Image (MRI)
The insurer denied: Lumbar Spine Magnetic Resonance Image (MRI)
The denial is upheld.

The patient is an adult male.  The patient presented for evaluation of hip pain; he had slipped and fell on the ice during the winter.  The pain was located over the lumbosacral junction.  The patient has tried cannabidiol (CBD) and over-the-counter arthritis medications without relief.  He had attended physical therapy for six weeks at two visits per week; this mildly decreased the symptoms.  The patient's reflexes are intact; sensation is intact.  No imaging was obtained at the office visit.  A magnetic resonance image (MRI) of the lumbar spine was ordered.
Physical therapy documents the patient had had a total of 16 visits since the start of care.
Left hip x-rays show cam changes bilateral femoral heads with mild acetabular osteophytic changes and possible extensive lower lumbar degenerative disc disease.
The National Imaging Associates denial notice states that the lumbar spine magnetic resonance image has been denied and is not medically necessary.  This was based on the National Imaging Associates (NIA) Clinical Guideline 044 Lumbar Spine Magnetic Resonance Image (MRI).  The notes did not show the dates that the patient did six weeks of back exercises in the last six months.

The proposed treatment is not medically necessary.

The procedure is not in accordance with the generally accepted standards of medical practice. Per generally accepted standards of medical practice, an x-ray of the lumbar spine should be done prior to ordering advanced imaging. In addition, per generally accepted standards of medical practice, a clinical re-evaluation after the completion of conservative treatment should be completed.  Based on the records provided, there are no notes provided after the patient was discharged from physical therapy.

The procedure is not clinically appropriate for this patient at this time as a magnetic resonance image (MRI) of the lumbar spine is not clinically appropriate in the setting of a normal neurological exam without prior x-rays of the lumbar spine. There is no documentation of a plain x-ray of the lumbar spine.  There are x-rays of the elbows and hips which on the reports show degenerative disease of the lumbar spine, however these are not designated films of the lumbar spine.  While it is not suggested the procedure was mainly for the convenience of the doctor or other healthcare provider, a magnetic resonance image of the lumbar spine is more advanced than a plain x-ray and should be reserved for after a plain x-ray of the lumbar spine has been completed in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is upheld

The patient is an adult female with history of chronic obstructive pulmonary disease (COPD), asthma and hypertension (HTN). She presented to the emergency department (ED) with complaints of (C/O) shortness of breath (SOB), cough and wheezing. The patient was noted to have bilateral (B/L) wheezing with oxygen (O2) saturations on Room Air of 94%.

She was treated with intravenous (IV) Steroids, Magnesium, Fluids and bronchodilators (BD) in the ED. The patient was placed on O2 and continuous positive airway pressure (CPAP) and admitted to hospital for COPD / Asthma exacerbation.

As per admission history and physical (H&P): Temperature 98.3 F (Fahrenheit), Blood Pressure 119/68, Heart Rate 58, Respiratory Rate 18, and oxygen (O2) saturation on Room Air of 94%. The patient was in no acute distress (NAD) lung exam revealed wheezing. The patient was placed on CPAP, Cardiovascular system (CVS) was unremarkable, abdomen soft non tender (NT) and she was alert and oriented x 3.

White blood cell count (WBC) 7.1K (thousand), Hb (hemoglobin) 15.7, electrolytes showed a K+ (potassium) of 5.8, Chest x-ray revealed (CXR) no acute Infiltrates. Ultrasound was negative for Deep vein thrombosis (DVT).  Liver function test (LFT's) showed mild transaminitis.

By the next day the patient was improving, she was afebrile, (O2) saturations on Room Air of 96-99 %.  Lungs revealed wheezes. The patient was tolerating oral food and fluids and was ambulatory. 

The WBC (white blood cell count) had increased to 15 K, likely a steroid effect, with no signs of any infection. An US (ultrasound) revealed some fatty liver and the echocardiogram (ECHO) was within normal limits.

The patient remained stable and was switched to PO (oral) steroids and PO antibiotics (Abx) and discharged home.

Based on the above, it appears that patient could have been placed in observation status and once she remained stable overnight and other serious conditions ruled out, she could have been discharged home on PO Steroids, PO Abx if needed, bronchodilators and close follow up in outpatient setting.

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 level of care services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes.

Treatment is an inpatient admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is overturned.

This is a child who presented with fatigue. The glucose was 421. PH (potential for hydrogen) was 7.37. The beta hydroxybutyrate was 0.3. The patient received a normal saline bolus. The patient was given 6 units of Humalog and admitted for further management. The patient has an A1c (glycated hemoglobin) of 11.2%. Subcutaneous insulin was begun. Diabetes education was initiated. The glucose levels quickly stabilized after the patient was started on a basal bolus regimen of insulin using Levemir and Aspart. The patient was discharged after completion of diabetes education.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components [1, 2]. 

The majority (75%) of medical centers in the US (United States) [3] that treat new onset diabetes admit their patients. According to the ADA (American Diabetes Association) statement on treatment of type 1 diabetes [4], hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  In treating diabetes, the initial hospitalization is to educate the patient and the family in self injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3-day admission to the hospital. 

The patient presented with a hemoglobin A1c of 11% and therefore required an inpatient admission for insulin initiation. The patient's family had a language barrier and required a slightly longer admission to complete all diabetes education.

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 the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

Per clinical documentation, this patient presented to the emergency department with right upper quadrant abdominal pain. Vital signs in the ED (emergency department) were within normal limits. The patient was afebrile. An ultrasound demonstrated cholelithiasis with a positive Murphy's sign. There was borderline distention of the common bile duct measuring up to 6mm (millimeters). Liver function tests were normal except for alanine phosphatase that was mildly elevated at 127. A magnetic resonance cholangiopancreatography (MRCP) was performed and there was no indication of choledocholithiasis. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. 

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. [9] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6] Per MCG (Milliman Care Guidelines) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation. [7]

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gallbladder disease and a dilated common bile duct
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient came to the Emergency Room with weakness and decreased oral intake. She was found to have a dilated common bile duct and a porcelain gallbladder. She left the hospital prior to the computed axial tomography scan results being available and was called back to the hospital. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A magnetic resonance cholangio pancreatography (MRCP) was advised but the patient decided not to stay in the hospital. 

Milliman Care Guideline (MCG) Clinical indications for admission for Gallbladder or Bile Duct inflammation or Stone (MCG M-555) include having acute cholecystitis or acute cholangitis. This needs to be manifested by having gallbladder or bile duct disease as well as systemic signs of inflammation. In this case, the patient did not have systemic signs of inflammation. She also did not have hemodynamic instability, a complete bile duct obstruction, severe vomiting, severe dehydration, or bacteremia.

The patient required further workup for gallbladder disease and a dilated common bile duct. No surgical interventions were planned at this time. The MRCP, and if necessary, an endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction, could have been scheduled as an outpatient. She did not have systemic signs of inflammation and did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone.

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

The insurer's denial of coverage for an inpatient is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Hospital Admission
The insurer denied coverage for hospital admission
The denial is overturned.

The patient is a female child with a history of autism who had been sick for four days with a fever and a cough. Three days prior to the admission the child had been seen at outside hospital Emergency Room (ER) and was diagnosed with metapneumovirus. On the day prior to the admission, the child was seen by the primary care pediatrician and was diagnosed with bilateral otitis media and was prescribed amoxicillin. The father administered two doses of the antibiotic. The father noted that the child appeared more tired and had a decrease in activity with a significant decrease in oral intake and urine output, so he decided to bring the child to the ER for additional treatment.

In the ER, the child was noted to tachypneic and had retractions. On physical examination, the child appeared dehydrated and was noted to have decreased breath sounds and crepitations over the right lung. A chest x-ray showed perihilar infiltrate consistent with pneumonia. Blood testing indicated an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). The medical history obtained indicated that the father had also been sick with a cough and fever for several days. The child was treated with a bolus of intravenous (IV) normal saline. Based on the prolonged illness with the development of increased respiratory effort with crepitations, pneumonia on chest x-ray and blood testing demonstrating an inflammatory process the child was diagnosed with pneumonia and the decision was made to admit for IV fluids and ceftriaxone.

This patient was treated appropriately in the ER for a diagnosis of pneumonia following a prolonged illness. She had an elevated CRP and ESR, crepitations heard in the right lung and a chest x-ray also consistent with a right sided pneumonia. The child was not tolerating oral liquids and had a decrease in urine output that required an IV fluid bolus of normal saline. The child had received 2 doses of Amoxicillin in the home for an otitis media diagnosed by the pediatrician on the day prior to the admission but the child was unable to take the medication. The decision to admit the child to the hospital with a diagnosis of pneumonia and dehydration was appropriate and consistent with the standard of care for treatment of pneumonia in a child with a pneumonia and inability to tolerate oral fluids and antibiotics. The child was not stable enough to be discharged with oral antibiotics.

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 the hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular accident (CVA)

Treatment: Inpatient hospital admission 

The insurer denied coverage for an inpatient hospital admission. 
 
The denial is upheld.

This male patient was seen in the emergency department (ED) with complaints of left leg weakness with no other symptoms. A computed tomography (CT) of the head showed an infarct involving the high right parasagittal parietal lobe. The tPA (tissue plasminogen activator) was not administered. He was started on aspirin, Plavix, and a high intensity statin. His left arm function improved. His Rankin scale was 4+. He was very cooperative and a good candidate for rehabilitation. 

The discharge summary states he has cerebrovascular accident (CVA), left leg paresthesia and improving left arm weakness. The magnetic resonance imaging (MRI) showed an acute/subacute right parietal lobe infarct.

Medical records indicate that the patient was stable and required no further inpatient treatment. The continued inpatient hospital admission is not considered medically necessary for this patient. As per MCG (Milliman Care Guidelines), goal LOS (length of stay) is 2 days.  

According to Khaku, A. S., and Tadi, P. (2022), "A stroke, or cerebrovascular accident, is an emergency medical condition characterized by an acute compromise of the cerebral perfusion or vasculature. The leading cause of ischemic stroke is hypertension whereas clotting disorders, carotid dissection, and illicit drug abuse are common causes in the younger populations. A quick diagnosis followed by prompt management needs to be set in motion by the interprofessional team members to improve outcomes for those with stroke. This activity reviews the etiology, presentation, evaluation, and management of cerebrovascular disease and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition."

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 continued inpatient hospital admission is upheld. Medical necessity is not substantiated.