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

Diagnosis:  Back pain.
Treatment:  Inpatient admission and 22610 - Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed), T3-11.
The insurer denied Inpatient admission and 22610 - Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed), T3-11.  The denial is upheld.

The patient is an adult female with chronic mid back pain for several years.  She is a smoker.  She has some radicular pain to the right lateral hip region.  She has had physical therapy and tried bracing, NSAIDs (nonsteroidal anti-inflammatory drugs) and medical marijuana.  She denies any inciting event. 

The patient's physical exam reveals tenderness in thoracic spine.  She has 4+/5 strength in knee flexion/extension and hip flexion.  X-rays show no exaggerated kyphosis or scoliosis with degenerative changes.  MRI shows disc herniations with mild stenosis.  AP recommends Thoracic fusion T3-11. 

This patient has no deformity (scoliosis or kyphosis), instability (fracture, spondylolisthesis) or significant stenosis to warrant surgery of any kind.  Surgery would be contra-indicated in this patient because of her smoking and lack of pathology.  Just because non-surgical treatment fails does not mean that surgery is necessary.  The recommended surgery is not clinically appropriate for this patient and not consistent with standards of care in the medical community.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: HTN; Diabetes; Dementia
Issue under review: Increase in personal care assistance

Determination:
The health plan denied Increase in personal care assistance. The health plan's denial is upheld.

This is an elderly female with a history of hypertension, uncontrolled diabetes mellitus, congestive heart failure, dementia and bowel/bladder incontinence. Due to restrictions/limitations related to these conditions, she requires assistance with completion of the majority of her activities of daily living (ADLs). However, an in-home assessment completed indicated that the currently approved plan of personal care assistance is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional decline since the date of this last assessment. Hence, the proposed treatment of an increase in personal care assistance is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration and hypoglycemia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a male child. He has a complicated medical history and has been on GJ (Gastro-Jejunal) tube feeding. He had GJ tube dysfunction and was hospitalized.
A brief summary of the hospital stay is as follows:

(ED note and admission H&P [history and physical exam]) patient pulled the tube, and then GI (gastrointestinal) tube started leaking. No fever, vomiting or other symptoms. Test showed hypoglycemia and received IV fluids.
Plans: admit for dehydration/IV fluids and GJ tube replacement.
Continued on IV fluids and glucose for dehydration.

(Discharge summary) Transferred to another hospital for his GJ tube replacement.

As documented in clinical information and summarized below, this patient had GJ tube dysfunction and was found to have dehydration with hypoglycemia. He was hospitalized to receive IV fluids and to correct his hypoglycemia.   

During the hospital stay, the patient was comfortable. He did not have any fever, vomiting or other symptoms. Except IV fluids and dextrose, the patient was stable with no acute events or intervention, such as fever, vomiting, respiratory distress, and cardiac problems. Therefore, the inpatient admission was not medically necessary. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Incomplete uterovaginal prolapse
Treatment Inpatient Hospital Stay. The insurer denied Ipatient Hospital Stay.
The determination is upheld.

The patient underwent a vaginal hysterectomy along with anterior/posterior repair, sacrospinous ligament fixation, transvaginal tape (TVT), and cystoscopy. The procedure was reported to be without complication. She stayed one night in the hospital and was discharged the day after surgery. An inpatient stay is under review for medical necessity. There was nothing unexpected reported in this patient's care that would elevate the care to the level of an inpatient admission. The patient's vital signs were normal the day after surgery. The American Congress of Obstetricians and Gynecologists (ACOG) outlines criteria for discharge after outpatient procedures, and states vital signs need to only be within 20% of baseline. The physician notes on postoperative day 1 suggest a routine postoperative course with the discharge prior to noon (about 24 hours after the patient's surgery was completed). The management described in the record on the day after surgery included oral pain medication, spontaneous voiding, and tolerating an oral diet; these are traditional targets for discharge that appear to have been reached. The urogynecology procedures add to the operative time, but are all within the scope of a one-night hospital stay. There were no complications documented, so the inpatient admission was not medically necessary.

An inpatient level of care for this patient was not medically necessary. The vaginal procedure is reported to have been performed as planned without intraoperative complication. The morning after the surgery, the patient's indwelling Foley catheter was removed and she voided. There had been concerns over urinary retention, but that is a common issue after urethral sling placement. Her vital signs were normal, and pain was described as managed. She tolerated a regular diet. There is no documentation in the physician notes of any complications or unexpected events during her stay. Her blood pressure and other vital signs were normal the day after surgery. Urine output was documented to be adequate. No blood products or extra fluids were administered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, hypertension 
Treatment: Consumer directed personal care assistance 

The insurer denied Consumer directed personal care assistance. The denial is upheld. 

This is a female with a past medical history pertinent for stroke and hypertension. The patient and her family report that due to impairments related to her conditions, she requires assistance with completion of some of her activities of daily living (ADLs). However, an in-home assessment of the patient's clinical functionality and ability to complete ADLs was performed. This assessment revealed that the patient is able to perform toileting, personal hygiene and can ambulate independently. Furthermore, the M11Q form signed by her physician failed to demonstrate any indication for ADL assistance. For these reasons, the proposed treatment of consumer directed personal care assistance is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with a past medical history significant for hypertension (HTN), diabetes, cerebral vascular accident (CVA) with residual left hemiparesis, and transient ischemic attack (TIA). 

The patient presented with a complaint of sharp mid-sternal non-exertional chest pain. The patient was bradycardic on admission to the nadir of 49, with improvement in heart rate (HR) to low 60's, stable blood pressure.  Cardiac troponins were negative. Electrocardiogram (ECG) revealed normal sinus rhythm with non-specific changes.  Prior nuclear stress test within a year was normal.  No repeat stress test was planned.  Echocardiogram was obtained and revealed normal left ventricular (LV) systolic function.  Oral (PO) medical therapy was continued and intravenous (IV) fluids were given.  The patient was discharged home with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain.  The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative.  There was no plan for inpatient ischemic work-up.  There was no need for pacemaker or vasoactive drips.  There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Treatment:  Inpatient hospital

The patient is a male with type 2 diabetes, hypertension and previous patent foramen ovale (PFO) closure who presented to the emergency room (ER) with chest pressure which began while he was doing yard work.  He contacted Emergency Medical Services (EMS), and was given aspirin and nitroglycerin (NTG).  His symptoms resolved.  In the ER, blood pressure (BP) was 148/80 mm Hg, pulse 66 beats per minute (bpm) and respiratory rate 18.  His oxygen saturation was 98% on room air.  A chest x-ray (CXR) showed no acute infiltrates.  An electrocardiogram (EKG) showed sinus rhythm at 66 bpm and an incomplete right bundle branch block (RBBB).  Troponin was normal, at < 0.012.  He was admitted, and ruled out for myocardial infarction with 2 negative troponin levels. 

The health plan's determination is upheld.  The inpatient stay is not medically necessary. The patient presented to the hospital with chest pain.  He was hemodynamically stable, and without objective evidence for an acute coronary syndrome.  Therefore, a lower level of care is appropriate.  He had been ruled out for myocardial infarction and had no further chest pain or other acute cardiac or pulmonary illness requiring hospitalization, such as pulmonary edema, pulmonary embolus, or aortic dissection.  The inpatient admission is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Asthma
Pharmacy/Prescription Drugs

The patient is female with severe asthma on multiple Inhaled corticosteroids/LABA. She was noted to have abnormal PFTS (pulmonary function tests) inspite of the maximum dose. Many times, the RV (residual volume)/TLC (total lung capacity) was elevated and FeNO (exhaled nitric oxide) was less than 20. She was on Oral corticosteroids 3 to 4 times in last 12 months. The treating pulmonologist recommends Dupixent.

The health plan's determination is overturned. Dupixent is medically necessary for this patient. The patient has severe persistent asthma at an adolescent age. This is an ideal set up for Near Fatal Asthma or Fatal Asthma. Numerous studies have shown that poor response to maintenance medication and poor "perciever" status of the disease state from the teen/Adolescent age has contributed to the fatalities in asthma (which is often referred to as near fatal asthma or fatal asthma). Patients with severe persistent asthma are at high risk of asthma exacerbations, and face an accelerated decline in lung function and impaired quality of life. Several studies have shown that daily maintenance therapy in severe persistent asthma could prevent the near fatal asthma. Literature sources suggests strongly that Dupilumab can positively affect the disease progression by reducing the emergency department (ED) visits/Asthma exacerbations. Even though the eosinophil is < 250 , this patient will benefit because the 2018 The New England Journal of Medicine (NEJM) article suggests clinical benefit in spite of absence of eosinophilia. In order to contain the rapid decline of lung function and to prevent a severe outcome such as fatal asthma or near fatal asthma, the Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of repaired pulmonary stenosis and Pediatric Intensive Care Unit (PICU) admission 4 months prior for dehydration, hypernatremia and acute kidney injury who presented with nonbloody diarrhea for 8 days' no fevers, vomiting or recent travel. The patient takes Israeli Similac at baseline about six ounces every four hours (6 oz q 4hrs and solids). When the diarrhea was not resolving, her mother gave only sugar water and ginger ale for 2 days. She then gave lactose free formula for the 3 days prior to going to her primary medical doctor (PMD) on the day of presentation. The patient had about 10 diapers with stool within the prior 24 hours and multiple episodes of diarrhea the days prior to that. She was having some decreased by mouth (PO) intake due to the constant diarrhea and decreased urine output. Her mother endorsed all oral intake "goes right through her". She reports the patient has an appetite and cries because she wants food.
In the emergency room (ER) she was afebrile heart rate (HR) 126, respiratory rate (RR) 22, and blood pressure (B/P) 111/62. She was described as tired appearing with capillary refill of 2-3 seconds. She appeared dry but interactive. She received a normal saline (NS) bolus x 2. Lab results were significant for white blood cell count (WBC) of 20.2, hemoglobin (Hgb) of 15.2, sodium (Na+) 130 and bicarbonate of 15 with anion gap (AG) of 14. The patient was admitted for intravenous (IV) rehydration in the setting of AG metabolic acidosis due to profuse diarrhea and likely starvation ketosis. On the floor, the patient was initially on 1.5 M intravenous fluids (IVF). She continued to have diarrhea, however, no fevers and stable urine output. On hospital day (HD) number (#) 2, IVF were weaned to 1M. Lactose free milk was introduced. On HD #3 she only had one bowel movement (BM) in 24 hrs, soft and formed. She was able to tolerate lactose free formula and IVF were discontinued. Based on her stable vitals, overall improved condition, ability to tolerate PO and resolving diarrhea, she was cleared for discharge home. Nystatin was given for diaper rash. The patient was instructed to follow up with the PMD in 1 day.
At issue is the medical necessity of an inpatient level of care.
The health plan's determination is overturned. The patient was treated in the emergency room with 2 normal saline boluses but given her history of PICU admission for dehydration in the past which included hypernatremia and acute kidney injury as well as mother, for the past 8 days, attempting oral rehydration as an outpatient with no success, admission would be warranted. Her laboratory studies showed hyponatremia, metabolic acidosis and her CBC also evidenced significant hemoconcentration with Hgb of 15.2 that after 24 hrs of hydration dropped to 11.6. This patient would require IV hydration to compensate for her GI losses that she was unable to match orally.
Based on current criteria, this patient was a candidate for admission due to her inability to maintain oral hydration (eg, needs IV fluid support) in the face of persistent diarrhea.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, nausea, vomiting
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female child with medical history significant for minimally-verbal autism that presented to the emergency department (ED) with four-day history of decreased intake, two-day history of fever to 104, and one-day history of vomiting. She had been admitted two months prior with gastroenteritis and dehydration. 

Vital signs included temperature 97.7, heart rate 110, respiratory rate 21, and blood pressure 109/76. Examination was significant for tired appearance with sunken eyes, benign abdomen with no guarding, and non-focal neurologic exam. Bedside glucose was 85. Laboratory evaluation was significant for normal white blood cell (WBC) count (14.5K) with left shift (87.5%), mild hyponatremia (134), mild hyperkalemia (5.1), metabolic acidosis (CO2 15), and mild hyperphosphatemia (5.6). She was treated with Zofran and two normal saline boluses followed by maintenance intravenous (IV) fluids. She was subsequently admitted for further management. 

Admission orders included maintenance IV fluids, anti-pyretics, and urine studies. She had no further fevers or vomiting overnight. She was taking food and fluids near baseline. Urinalysis was significant for concentrated urine and ketonuria but was otherwise negative for infection. Both urine culture and throat culture were negative. She was subsequently deemed stable for discharge.  

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.

This female child with autism and previous long admission for dehydration due to gastroenteritis presented to the ED with signs and symptoms consistent with acute viral gastroenteritis. She was found to have significant metabolic acidosis on laboratory evaluation. She was treated with two fluid boluses prior to admission. However, after admission she had no further fevers or episodes of vomiting and she did not develop diarrhea. While it was reasonable and appropriate to monitor her in the hospital for resolution of vomiting with subsequent rehydration, she was overall stable and did not require acute inpatient admission. She could have been safely managed at a lower level of care while receiving the same attention to her symptoms and the same interventions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male. His medical history included hypertension and dyslipidemia; his surgical history included vasectomy. The patient presented to an emergency department with a one-day history of right lower quadrant abdominal pain and nausea. 

The patient's vitals were temperature 99.2, pulse 98, blood pressure 143/84, respirations 16, and oxygenation 99%. Physical examination demonstrated tenderness to palpation of the right lower quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 12.70. Computed tomography demonstrated acute appendicitis. 

The patient was admitted to acute inpatient level of care with a diagnosis of acute appendicitis. He was made nil per os [NPO]; and provided with intravenous fluids, antibiotics, and analgesics. That same day, the patient underwent laparoscopic appendectomy -- surgery and recovery were unremarkable. The following day, having returned to his baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up and oral analgesics. 

This patient could have been treated at a lower level of care. 

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et al]. In fact, most patients can be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission [Mitchell et al; Dubois et al; Cash et al]. Therefore, for this patient, there was no need for admission at an acute inpatient level of care. 

Patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal Class II malocclusion, mild maxillary crowding and mild mandibular crowding.  The proposed treatment is braces with 8 monthly visits.  The issue for review is the medical necessity for braces and the 8 monthly visits.
The health plan's determination is upheld.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 8 with no auto qualifiers.  Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater.  The case requires a score of 26 or more for treatment to be considered medically necessary.  The malocclusion in question does not meet the criteria to be classified as handicapping, and treatment would not be considered medically necessary.  Thus, braces and the 8 monthly visits are not medically necessary for this patient.