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

Diagnosis: Bronchiolitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This is a young child who had been coughing with nasal congestion for several days and she had been seen for 2 recent emergency room (ER) visits. The day prior to admission she developed a fever of 104 degrees and her nasal discharge became mucoid. The mother was concerned and brought her to the ER for evaluation.

In the ER she was noted to have a fever of 103 degrees Fahrenheit, and she was noted to be in respiratory distress with coughing. On physical examination she was noted to have nasal flaring, a rapid respiratory rate with retractions and wheezing. She was treated with duoneb and Decadron. The white blood count was elevated at 26.8 and a blood gas showed a respiratory acidosis with a pH (acidity) of 7.3 and a partial pressure of carbon dioxide (PCO2) of 55. Based on her respiratory distress and abnormal blood test results the decision was made to admit her to the hospital for ongoing treatment with a diagnosis of bronchiolitis.

The patient was treated appropriately in the ER for coughing, wheezing and increased work of breathing. Her increased work of breathing and wheezing did not respond to treatment with bronchodilators and dexamethasone. The decision to admit with a diagnosis of bronchiolitis for continued observation and treatment with normal saline and albuterol every 3 hours was medically indicated and the child could not have been safely discharged to home. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Laceration. 
Treatment: Inpatient Admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld.  

This case involves a child who sustained a vaginal laceration after landing on a metal slide. She was seen at the hospital on the date of her injury for laceration repair. Her vital signs were stable. Her preanesthetic evaluation noted the vaginal laceration where upon she was to undergo a vaginoscopy with cystoscopy and a laceration repair. Following surgery, the patient met criteria for discharge and was signed out by anesthesia. 

An appeal was submitted stating that the patient was admitted for the management of a vaginal laceration and a full examination was limited by the patient's pain and anxiety. The report went on to state that the inpatient plan of care included preoperative optimization, intravenous hydration, and pain management. The surgery consisted of examination under anesthesia with a repair of the posterior vaginal laceration.  

The Milliman Care Guidelines state that patients who have sustained a vaginal laceration can be cared for on an outpatient basis. The information provided for the review did not include any evidence of hemodynamic instability, excessive bleeding, or a significant injury that would require an acute level of care. Therefore, while it was noted that the patient was of a young age with reports that she was unable to be fully examined and required sedation, the extent of treatment to include examination under anesthesia with laceration repair could have been safely and effectively completed on an outpatient basis. The inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: inpatient admission 

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult who presented to the emergency department (ED) with right lower extremity cellulitis. The patient had a history of uncontrolled type II (2) diabetes with neuropathy and increased erythema to the right lower extremity with associated fevers and chills was noted. He had previously undergone surgical debridement of an ulcer and application of a tissue graft for the same extremity and was followed as an outpatient while on a course of oral antibiotics. Per the records, the cellulitis was not extending from this site on the right dorsal foot. On admission, the patients White blood cell count (WBC) was 11.6. The patient exhibited tachycardia up to 106 and a fever up to 100.7 degrees Fahrenheit. During his stay the erythrocyte sedimentation rate (ESR) was elevated to 76 and the C reactive protein (CRP) to 25.043. Upon discharge the patients' elevated labs all decreased while he was on intravenous (IV) antibiotics.

The patient was an uncontrolled diabetic with elevated inflammatory markers and white blood cell count (WBC), and he required an inpatient admission.  

Diabetic foot infections can be life threatening and patients with these infections consistently suffer from a plethora of underlying conditions that require a multi-specialty approach to treat.  As such, timing and surgical intervention is crucial, which was the case in the presentation of this patient, who had to be admitted and consulted by various specialties, thereby making this a justified admission. Furthermore, due to diabetes patients with an infection may never "mount a robust systemic response," thereby complicating factors that may be deemed as necessary for admission, which again justifies the reasoning behind the admission. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

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

This case describes a female patient who sustained a fall at home after she stood up to go to the bathroom. She was then seen at the emergency department where radiographs confirmed a right femoral neck fracture. The patient was admitted for further definitive care. 

The inpatient hospital admission was not medically necessary for this patient. The medical records in this case document that this patient sustained a fall at home resulting in a non-displaced right femoral fracture. The patient underwent screw fixation of this right femoral neck fracture. This surgery was completed successfully with no documented complications. This procedure was consistent with the current standard of care for a non-displaced femoral neck fracture as documented by Okike and colleagues in the Journal of the American Academy of Orthopedic Surgeons. There is no documentation of any post operative infection or complications that would necessitate an inpatient hospital admission for this patient. The provided records contain a progress note in which the orthopedic provider documented that the drop in hemoglobin was not actionable and that the patient was doing well from an orthopedic standpoint. The patient was stable for discharge to a short term rehab facility. Therefore, the care rendered in this case did not require a full inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo (dizziness)
Treatment: Inpatient Stay
The health plan denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with a history of a cerebral aneurysm status post clipping who presented to the emergency room with dizziness. The patient reported multiple episodes of dizziness previously. The patient underwent a computed tomography (CT) of her head that showed no acute changes. The CT of her head showed evidence of a prior craniotomy consistent with known aneurysm clipping. The patient's dizziness improved and it was recommended that she use Meclizine for symptom control. The patient was scheduled to follow-up with neurology as an outpatient.

The requested health service was not medically necessary. An acute inpatient admission for the evaluation of dizziness was not medically necessary. The patient has a history of dizziness and was admitted to the hospital with similar symptoms. At the time of presentation, the patient had stable vital signs and laboratory data. There was no indication for an acute admission to the hospital. Although history of a cerebral aneurysm is a factor, dizziness is a common emergency department complaint and the history of an aneurysm alone cannot be used to justify an inpatient admission. The patient had no acute imaging findings and the dizziness resolved with time and the use of Meclizine.  There was no stroke detected or ruptured aneurysm or emergent hypertension. There were no services provided consistent with an acute admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The determination is upheld.

The patient has a history of asthma. Her presenting complaints were a dry cough, nasal congestion, and dyspnea, progressively worsening over the preceding 3 weeks. She had discussed this with her outpatient pulmonologist and was taking prednisone and had completed a course of azithromycin. On arrival to the emergency department, the patient's vital signs were blood pressure 113/67, heart rate 111, respiratory rate 26, with an oxygen saturation of 98 percent (%) on room air. The physical exam in the emergency department (ED) was notable for no acute distress, bilateral wheezing, and no use of accessory muscles. Lab results were notable for a blood gas, documented as from an arterial source, as 7.41/51/46. Radiology was notable for a chest x-ray showing mild pulmonary vascular congestion. At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary. The patient presented with signs and symptoms consistent with a mild to moderate asthma exacerbation. Her physical exam on presentation to the emergency department (ED) demonstrated no acute distress or accessory muscle use. Her trajectory over her ED course and initial course was good and wheezing was intermittently documented as present, and absent, over this time period. Care could have continued at a lower level safely. Of note is the patient's arterial blood gas showing a mild primary metabolic alkalosis with respiratory compensation; this would not be the pattern expected to occur in an acute asthma exacerbation.

For the reasons stated above, a lower level of care would have been appropriate for continuing to manage this mild-moderate asthma exacerbation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plantar Fascial Fibromatosis and Flat Feet
Treatment: Foot Inserts
The insurer denied the request for foot inserts.
The health plan's determination is overturned.

The patient is a female who was seen for a chief complaint of severe pes planus with pronation syndrome and plantar fasciitis. The patient has been complaining of pain to both of her feet with fatigue with ambulation for 6 months. The patient is also complaining of consistent arch pain. The condition is worsening and is only relieved when she is not walking. On exam, the patient is noted to have severe pes planus with pronation syndrome bilaterally with plantar fasciitis. She has a functional limb length discrepancy. The patient has pain on palpation of the sinus tarsi joints as well as along the posterior tibial tendons. The patient was diagnosed with plantar fasciitis, posterior tibial tendonitis and pes planus deformity. 

Based on the review of the submitted records and current literature, the requested health service and treatment of foot inserts is medically necessary for the patient. The patient has had pain for over 6 months and has been diagnosed with plantar fasciitis, posterior tibial tendonitis and severe pes planovalgus deformity. The patient has tried over the counter orthotics, shoe modifications, Achilles stretching, strapping, a change in activity and rest, nonsteroidal anti-inflammatory drugs (NSAIDs) as well as physical therapy which have not helped. Thus, the next medical treatment to help relieve pain would be custom molded orthotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Painful feet from a foot condition (ankle pain, plantar fasciitis and pes planus).
Treatment:  Left Foot Inserts.

The insurer denied the request for left foot inserts.  The health plan's determination is upheld.

The patient is a female, who was seen with a chief complaint of severe plantar fasciitis. The patient has been complaining of pain in both of her feet and fatigue with ambulation for the past 3 months. The patient is complaining of arch pain with plantar fasciitis. On exam, the patient was noted to have severe pes planus with pronation syndrome bilaterally with plantar fasciitis. There is also a functional limb length discrepancy. The patient has pain on palpation of the sinus tarsi joints, as well as along the course of the posterior tibial tendons. There is some edema noted. The patient was diagnosed with plantar fasciitis, posterior tibial tendonitis and flat foot. There is a recommendation for the patient to have custom molded orthotics.

After a review of the submitted medical documents, the requested health service and treatment of left foot inserts is not medically necessary for the patient. The patient has tried conservative treatment with physical therapy (PT), nonsteroidal anti-inflammatory drugs (NSAIDs), strapping, rest, ice, and shoe modifications, which have failed. The patient has had pain for the past 3 months. The documentation has failed to show an adequate amount of time for a course of conservative care before recommending custom molded orthotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Augmentin induced liver injury. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient presented with epigastric and joint pains. She was recently seen for a sore throat and was started on Augmentin. She was afebrile and the vital signs were stable. The abdominal exam was benign. The liver enzymes were elevated. The international normalized ratio (INR) was normal. An abdominal computed tomography (CT) scan showed a fatty liver with normal bile ducts and pancreas. Hepatitis serology was negative. She was diagnosed with Augmentin induced liver injury. The antibiotic was held, and her symptoms improved. 

According to Milliman Care Guidelines (MCG) Clinical indications for admission for Liver Disease Complications (MCG M-570) include having hepatic encephalopathy, hemodynamic instability, infected ascites, an INR of 2 or more, severe vomiting or dehydration, and acute liver necrosis. The patient did not have these conditions. 

This patient developed a drug induced liver injury from Augmentin. She needed to have the antibiotic stopped and her liver function monitored. She was not in acute liver failure and had a normal INR. Monitoring of the liver enzymes could have been done on an outpatient basis. She could have been managed with observation status. She did not meet MCG criteria for admission for Liver Disease Complications. 

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: S/p (status post) dilation and curettage for suspected missed abortion
Treatment: Inpatient Stay. 
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient is a female with a missed abortion at 6 weeks and 3 days gestation. She presented to the emergency department and an ultrasound showed an intrauterine pregnancy at 6 weeks and 3 days gestation without cardiac activity. The patient had a dilation and curettage with 500 milliliter (ml) blood loss. There was a concern that the tissue during the procedure was abnormal and consistent with a molar pregnancy. She had postoperative bleeding and received Methergine, Cytotec, Pitocin and an intrauterine balloon catheter was placed. The patient was admitted to the hospital as an inpatient. Her hemoglobin was 8.4. The balloon catheter was removed the following day. 

The inpatient admission was not medically necessary. The patient is a healthy female without any significant morbidities. She had an outpatient procedure with a complication of hemorrhage.

There was no need for an acute, inpatient admission. Her hemoglobin showed anemia however, she had no blood transfusions, changes in vital signs nor hemodynamic instability. Her bleeding was minimal at time of discharge. She had no anesthesia complications nor pulmonary, hepatic nor renal concerns.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hypertrophy.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an elderly male with a history of benign prostatic hypertrophy, lower urinary tract symptoms, incomplete bladder emptying, frequent urination who underwent a prior surgery complicated by post-operative bleeding, clot retention and re-catheterization with no benefit from the surgery and repeated episodes of gross hematuria and urinary retention. The patient required admission for hematuria after the surgery with indwelling catheter and continuous bladder irritation. The patient was medically cleared for bipolar vaporization and resection of prostate. Operative report notes the procedure went well with estimated blood loss (EBL) of ten milliliters (mL).  After the procedure, prior to being transported to the recovery room, hematuria was noted, and the patient was placed on continuous bladder irrigation. In the post-anesthesia care unit (PACU) the urine was bloody when the continuous bladder irritation (CBI) was clamped and thus the patient admitted for continuous bladder irrigation. The patient did well overnight, the catheter was removed, he passed a voiding trial and was discharged to home.

The proposed inpatient hospital admission was not medically necessary.

This patient was medically cleared for surgery, the procedure was uncomplicated. The patient did not require a transfusion, was hemodynamically stable, was not documented to have a bleeding disorder, or have any active co-morbidities that required acute inpatient care. The patient could have been monitored at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p cystoscopy with stent placement.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female who was brought to the hospital by an ambulance for fever, dysuria, abdominal pain and hematuria. The patient's past medical history is significant for kidney stones. The patient had low grade fever and tachycardia on presentation. The review of systems and physical examination were normal. Her laboratory studies showed a leukocytosis of 16.4. The patient underwent a cystoscopy and stent placement. The patient had an uneventful hospital course and was discharged the next day.

The requested health service and treatment of an inpatient stay was not medically necessary for the patient. The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. The patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or any unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control.
The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. An alternate level of care for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during an alternate level of care if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a man who presented to the hospital at the recommendation of his primary care provider. He had had a computed tomography (CT) scan in the outpatient setting to evaluate his known cirrhosis and portal hypertension. The CT scan showed extraluminal gas in proximity to the hepatic flexure of the colon and air within the wall of the transverse colon. He had no abdominal complaints at the time of presentation.

The Inpatient hospital admission was not medically necessary for this patient. This patient presented to the emergency department (ED) at the request of his primary care provider based on findings reported on an outpatient CT scan. He was clinically stable at the time of presentation. He did not require any acute intervention or surgical procedure. Vital signs were normal. He was monitored in the ED over a period of approximately 10 hours and was discharged from the ED with planned outpatient follow up. While there was a suspected acute intra-abdominal process and abdominal abnormalities noted on the outpatient CT scan, the patient had normal vital signs and a normal abdominal exam. He was able to be monitored in the ED over a period of several hours and discharged on the same day as presentation with planned outpatient follow up. Inpatient admission was not needed as the care and treatment provided could have been appropriately rendered with a lower level of care.