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

Diagnosis: Alcohol withdrawal, chest pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This male with a history of hypertension, coronary artery disease (CAD), alcohol abuse and withdrawal seizures presented complaining of chest pain, headaches, nausea and anxiety.  His last drink was the morning prior to arrival.  A plan for admission to detox was held due to complaints of chest pain. Vital signs were as follows: temperature 97.9, pulse 96, respiratory rate 18, blood pressure 157/104, and oxygen saturation 98%.  Troponin was negative.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 18.  Exam was unremarkable.  Labs were remarkable for a platelet count of 77.  Chest x-ray had no abnormality detected.  Electrocardiogram (EKG) showed no ischemic changes. 

The patient was admitted to the Intensive Care Unit (ICU) for alcohol withdrawal.  The plan of care included Valium protocol for alcohol withdrawal.   Day two, vital signs were stable. The patient was given a few doses of Ativan for withdrawal.  The patient was stable for floor transfer.  On day three, vital signs were stable.  The patient had no withdrawal symptoms.  He was cleared for discharge or transfer to the floor. 

No, the proposed inpatient hospital admission was not medically necessary. 

This patient with a history of alcohol abuse and withdrawal seizures was admitted for alcohol withdrawal after complaining of chest pain.  He was hemodynamically stable and afebrile.  He did not have persistent vomiting, delirium, seizures, or gross tremor.  There were no findings of severe alcohol withdrawal on exam.  Electrocardiogram (EKG) and troponins were not consistent with acute coronary syndrome.  The patient remained clinically stable during the hospital stay without acute withdrawal.  He did not have symptoms that required an acute inpatient level of care.  The Milliman Care Guidelines (MCG) for Substance-Related Disorders (Adult) criteria for inpatient admission are not met because the patient did not have signs of alcohol withdrawal, acute toxicity, severe dysfunction in daily living, or imminent danger to self or others.  The proposed inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Anemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This patient had prolonged vaginal bleeding with weakness, light headedness, and shortness of breath with exertion. Hemoglobin at presentation was 3.8. The patient was admitted for management of profound and symptomatic anemia with ongoing bleeding.

This degree of anemia with ongoing bleeding warrants hospitalization regardless of symptoms or even vital signs, as this degree of anemia is life-threatening including risk of cardiovascular collapse and stroke. Since the patient reported prolonged blood loss, it was necessary to transfuse packed red blood cells (PRBC) slowly in aliquots in order to prevent fluid overload from the transfusions. This required hospitalization and monitoring over days. Furthermore, the medical record details persistent vaginal bleeding, and therefore, continued blood loss. As noted in the refences below, it is difficult to assess the degree of blood loss from abnormal uterine bleeding (AUB). As such, to discharge the patient with significant anemia in the setting of continued blood loss would have been a clear deviation from the standard of care. Hospitalization for each of the days reviewed was necessary and within standard of care.

The health care plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient.

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

Diagnosis: Chronic Low Back Pain.
Treatment: 22899 - Unlisted procedure, spine (Intracept procedure).
The insurer denied the 22899 - Unlisted procedure, spine (Intracept procedure).
The denial is upheld.

The patient is a female with a history of chronic low back pain for over six months.  She has failed intrathecal (IT) pump placement, sacroiliac (SI) joint injections, trigger point injections, and opiate medications.  She has done physical therapy.  The patient's physical exam shows decreased flexion. An Intracept procedure has been recommended. The patient has a fusion for L1-L5 (first to fifth lumbar spine vertebra).  The procedure was denied as experimental/investigational. This was appealed.

No, the health plan should not cover the proposed treatment.

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic Type I or Type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.  However the patient is fused at the lumbar levels, therefore there should be no movement at the endplates or disc levels, and therefore a percutaneous procedure due to endplate pain is not medically necessary.  Pain from Modic changes are the result of movement and pressure at the level, however in an instrumented fusion, the movement is no longer present and Modic changed would not be the cause of low back pain. Of note, no Modic changes are seen on the submitted magnetic resonance image (MRI).  Therefore, the Intracept procedure requested is not medically appropriate.

No, the requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid Nodule

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

According to the documentation submitted, this is a patient with a history of chronic bronchitis, a thyroid nodule, gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension, and vitamin D (group of fat-soluble steroids) deficiency. He presented to the hospital for a scheduled total thyroidectomy with paratracheal node dissection.

Thyroidectomy has generally been considered an inpatient procedure. The American Thyroid Association (ATA) has established criteria for proper patient selection for outpatient thyroidectomy. Benefits of an outpatient thyroidectomy include cost, better patient satisfaction, and decreased exposure to nosocomial infections. Patients who are candidates for outpatient thyroidectomy include those who have reliable home support, transportation home, lives within driving distance of the medical facility, no impaired communication or language barriers, no previous problems with anesthesia, no prohibitive comorbidities, and not taking anticoagulation. [1, 2] 

Per clinical documentation, the patient presented for an elective thyroidectomy. A Jackson - Pratt (JP) drain was placed. The operative note was not provided, and there were no complications indicated after surgery. The Post Anesthesia Care Unit (PACU) notes indicate that the procedure was initially planned as ambulatory, but that the patient was admitted for "observation" due to nausea and difficulty drinking water. However, there is no indication that the patient had any difficulties tolerating oral (PO) intake once admitted to the surgical floor. The patient was subsequently discharged. According to Milliman Care Guidelines (MCG) criteria, goal length of stay is ambulatory. Inpatient stay may be needed for extensive thyroid carcinoma requiring lymph node dissection, severe active comorbidities, large substernal goiter, Graves disease with large goiter and elevated thyroid hormone, or complications of the procedure (i.e. postoperative hematoma, recurrent laryngeal nerve injury, postoperative hypocalcemia, or thyroid storm). [3] Per provided clinical documentation, inpatient admission was not medically necessary. Observation status would be more appropriate. 

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 hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: right lower extremity ulcer

Treatment: hospital admission

The insurer is denied coverage for hospital admission.

The denial is overturned. 

This male patient has a history of chronic kidney disease (CKD), hypertension, hyperlipidemia, vascular disease, diabetes mellitus type 2, and chronic right lower extremity ulcer.

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for right lower extremity wound/cellulitis. Magnetic Resonance Imaging (MRI) of fibula/tibia was negative for any osseous pathology. He underwent debridement of the wound. Nephrology consulted for renal insufficiency. Renal ultrasound was negative. Infectious Diseases recommended continuation of antibiotics. Vascular Surgery advised continue wound care. The patient improved clinically, remained afebrile and hemodynamically stable. He was discharged to continue oral antibiotics (Augmentin and Bactrim) and wound care as an outpatient. 

According to documentation, patient was referred to the hospital from wound center for worsening lower extremity ulcer. Patient was otherwise afebrile, but with elevated blood pressures. Laboratory results were notable for worsening renal insufficiency. Of note, patient's symptoms progressed despite a 10-day course of antibiotics. 

Based on above findings including failure of outpatient management in a high-risk patient, hospital admission was medically necessary for administration of intravenous antibiotics and surgical debridement.

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 hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overdose.

Treatment: Inpatient  admission.

Insurer is denied coverage for inpatient admission

The denial is upheld. 

This is a child with a past medical history of Autism Spectrum Disorder, whose only chronic medication is Clonidine, who was brought to emergency department (ED) for evaluation for a possible/ probable/ presumed overdose/ingestion of unknown amount of Clonidine and/or Melatonin. Incident if it occurred was not witnessed. She was in the same room playing with her twin sister who was brought lethargic and somnolent after the medication bottle was found in the same room. Mother denied any changes in behavior or activity, dizziness, confusion, fevers, chest pain, shortness of breath (SOB), abdominal pain, nausea, vomiting or diarrhea. Review of system in the ED was negative. Vital signs in the ED at arrival was essentially normal heart rate (HR) was 120 and blood pressure (BP) 90/52, re check 100/56 (Child is chronically on Clonidine). Echocardiogram (EKG) obtained was normal. Other laboratory studies obtained were essentially normal except for a slight elevation in prothrombin time (PTT) 42.4 (which was noted to have decreased by the next day), AST (aspartate aminotransferase) 52 (14-36), Alk Phos (alkaline phosphatase) 202 (38-126), and Ammonia 34 (9-30). Physical exam was completely normal showing a playful child in no form of distress or decompensation. The Admitting resident/physician diagnosis and assessment: "Possible accidental Ingestion. Admitted for observation for signs of toxicity, at the moment is stable and has shown no signs of deterioration." It is also noted that Social Services evaluation was requested.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This case involves a patient who has a history of asthma/chronic obstructive pulmonary disease (COPD), hypertension, prior cerebrovascular accident (CVA), atrial fibrillation, syncope, hypercholesterolemia, bipolar disorder, arthritis, and the use of anticoagulation who presented to the emergency department reporting loss of consciousness.  The documentation indicated she indicated her symptoms are associated with lightheadedness and dizziness.  Her prior fall was 2 days prior to presentation.  She did mention that she hit the right occipital region of her head during the fall and stated she has not been compliant with medications for the last week.  She also complained of right ear and neck pain.  She did indicate she followed up with ENT [ears, nose, and throat] specialist and was diagnosed with arthritis of right TMJ [temporomandibular joint].  The physical examination revealed a heart rate of 112.  She was in no acute distress.  She was alert and oriented to person, place, and time.  Sensation was intact as well as coordination.  There were no focal neurologic deficits.  Strength was 5/5.  The physician indicated there were no focal neurologic deficits appreciated and no change to sensation.  Her strength is 5/5 and there were no gait abnormalities with the use of a walker.  It was recommended she undergo laboratory diagnostic studies.  The documentation indicated a normal chest x-ray.  She had a negative troponin and white blood cells were 5.7.  She underwent a computed tomography (CT) scan of the head revealing no acute intracranial abnormality identified.  The physician indicated she did have syncope which is likely related to runs of atrial fibrillation with rapid ventricular response (RVR).  She was noted to be in a sinus rhythm.  The documentation indicated she was recommended to receive a dose of Lovenox however she refused.  The patient was admitted recommended to undergo consultation.  She did undergo a magnetic resonance image (MRI) of the head showing no significant changes.  Cardiology also recommended she utilize a loop recorder; however, the patient did refuse.  She continued with treatment and was recommended to undergo a lower extremity duplex however, again it was noted she refused this treatment as well.  She left against medical advice.

The patient had prior stroke and multiple stroke risk factors.  Unexplained syncope may have been of neurologic (e.g. stroke) or cardiac origin.  The admission for cardiac workup, monitoring and brain MRI was warranted, notwithstanding that the patient declined treatment, diagnostics and left against medical advice.

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 hospital admission is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Supraventricular Tachycardia

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is overturned.

The patient has a past medical history or hypertension, that presented to the hospital complaining of palpitations and lightheadedness while working.  He contacted emergency medicine services (EMS) and was noted to have a pulse of 214.  Electrocardiogram (ECG) revealed a tachycardia that was terminated with adenosine injection.  Upon presentation to the hospital, he had a pulse of 85 and a blood pressure (BP) of 141/80.  Physical examination was unremarkable.  12 lead ECG revealed normal sinus rhythm with no pre-excitation and no ischemic changes.  Serum blood testing revealed an elevated troponin of 0.057ng/ml (nanogram per milliliter) that peaked at 0.18ng/ml.  He was evaluated by a cardiac electrophysiologist and Electrophysiologic study with ablation was recommended.  He underwent successful ablation of typical AV (atrioventricular) node reentry tachycardia and was released the following day.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  This patient presented with lightheadedness and supraventricular tachycardia with rates in above 200bpm (beats per minute). Such patients require evaluation and treatment that typically involves invasive electrophysiologic study with ablation. (Reference 1) Moreover he had elevated troponin levels, a known predictor for hospital admission and health care resource utilization (Reference 2, 3). Given symptomatic rapid arrhythmia on ECG, inpatient hospital admission was medically necessary. This patient could not have been managed at a lower level of care. In conclusion, acute in-patient admission was medically necessary.

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

Diagnosis: Type 1 Diabetes Mellitus (DM)

Treatment: Jardiance 10 milligram (mg) tablet

The insurer denied coverage for Jardiance 10 milligram (mg) tablet.

The denial is overturned.

The patient is a male with type 1 diabetes mellitus (DM), and is requesting the use of Jardiance to help with blood sugar management. The plan denied Jardiance as off-label use for type 1 DM, and that information was not provided to support the use of Jardiance.

The provider sent a letter stating that there is an attached abstract which documents the safety and efficacy of empagliflozin (Jardiance) in type 1 diabetes. He further states the patient has been established on Jardiance with success.

"Empagliflozin improved glycemic control and weight in T1D [type 1 diabetes] without increasing hypoglycemia. Ketoacidosis rate was comparable between empagliflozin 2.5 mg and placebo but increased with 10 [milligrams]mg and 25 mg. Ketone monitoring for early ketoacidosis detection and intervention and lower empagliflozin doses may help to reduce this risk." (Rosenstock et al).

"We observed that the improvement in HbA1c [hemoglobin A1c] associated with 8-week adjunctive-to-insulin therapy with empagliflozin in patients with T1DM was associated with: 1) Trends toward improvement in glycemic exposure and the percentage of time spent in hyperglycemic and target ranges; 2) Significant improvement in two of the three measures of glycemic variability; 3) Trend toward improvement in glycemic exposure that was primarily explained by the improvement observed during nighttime hours despite a decrease in overnight basal insulin delivery; 4) Significant worsening in glycemic exposure and glycemic variability when empagliflozin therapy was discontinued; and 5) A similar magnitude of glycemic impact regardless of insulin pump or MDI [multiple dose injection] use. Although we previously observed a significant improvement in A1c (from 8.00.9% (percent) at baseline to 7.60.9% at end-of-treatment) [10], the lack of significance in the decrease in glycemic exposure as measured by AGP [acid glycoprotein) may relate to the effects of a concomitant decrease in basal insulin doses and an increase in the total carbohydrate intake over the 8 weeks of study." (Perkins et al 2015).

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

In patients with type 1 DM, it is difficult to maintain a consist/stable blood glucose level. These patients tend to have multiple complications related to their disease because of instability of their disease. This patient has been stable with the use of Jardiance, which is important as this reduces risk of the complication when blood glucose levels are more consistent and in range. Jardiance has been shown it can be effective in those type 1 DM, based on current medical literature.      

Jardiance 10 mg tablets is considered medically necessary for this patient.  

Based on the above, the medical necessity for the Jardiance 10 milligram (mg) tablet is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with a history of hypertension, hyperlipidemia and diabetes. He presented with the compliant of dizziness/vertigo, worse with change in position. 

At presentation, the patient's neurological examination was normal. CT (computed tomography) brain was normal. He was admitted for evaluation and treatment to the acute inpatient setting. His symptoms had resolved and he was discharged. 

No, the Inpatient admission was not medically necessary. 

The patient presented with dizziness/vertigo and had a normal neurological examination with end gaze nystagmus (normal finding), normal neuro-imaging and position dependent symptoms, which is inconsistent with TIA (transient ischemic attack)/stroke. There was nothing concerning from history of present illness or examination that would warrant acute inpatient admission. The clinical evaluation, diagnostic testing, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Full hospital admission

The insurer is denied coverage for full hospital admission.

The denial is upheld. 

This case involves a male who was taken to the Emergency Department (ED) via Emergency Medical Services (EMS) after having a witnessed seizure. The documentation indicated the patient's wife found him on the floor turning blue. Upon arrival EMS indicated the patient was postictal. The patient did detail a similar episode years prior. The physical examination revealed he was able to speak in full sentences and was in no acute distress. The oxygen saturation was 99% (percent) on room air. Blood pressure was 136/84 and pulse was 86 beats per minute (bpm). The documentation indicated the patient was recommended to undergo laboratory and diagnostic studies. The hemoglobin was 9.6 and white blood cells were 6.8. The blood oxyhemoglobin was 51.3. The computed tomography (CT) scan of the head revealed no acute intracranial abnormalities. An electrocardiogram (EKG) also revealed a sinus rhythm at 60 bpm with early repolarization. The recommendation was made to admit the patient for further observation and treatment. The documentation detailed he did undergo a Neurology consultation. The documentation does indicate he continued with additional treatment and did not have further significant adverse events. The patient was discharged the following day with instruction to follow-up with neurology and psychiatry.

Literature indicates a patient may be admitted when there is evidence of hemodynamic instability that persists beyond observation care. Additionally, when there is evidence that the patient is status epilepticus, there is a brain disorder requiring monitoring or intervention, cardiac arrhythmia of immediate concern, altered mental status that is severe persistent or when there is evidence of new focal neurologic deficits, an inpatient admission may be warranted. 

The documentation submitted does not detail the above. The documentation does not indicate the patient has any of the above indications warranting the requested inpatient admission. Therefore, while a short observation may have been appropriate for this patient, the requested inpatient admission was not medically necessary.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.