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

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Inpatient Hospital
The insurer denied: inpatient stay
The denial is: Upheld in whole

The patient is a female with a history of migraines and tobacco use. She presented to the emergency room with two very brief episodes of right arm numbness and difficulty speaking. The vital signs were normal. The physical exam, including the neurologic exam was normal. Except for a slightly elevated white blood cell (WBC) count, the labs were normal. The head computed tomography (CT) scan and the magnetic resonance imaging (MRI) of the brain were normal. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with low dose aspirin. Additional studies were performed including an electroencephalogram (EEG), venous Doppler exams of the lower leg, and an echocardiogram with a bubble test. All studies were normal and the patient was discharged the next day.

The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole.

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. The CT scan and MRI, which were completed on the day of presentation were unremarkable. Any additional studies could have been completed at a lower level of care status. Based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder, borderline personality disorder
Issue under review: Continued Inpatient admission 
The insurer denied the continued Inpatient admission.
The denial is overturned. 

Yes, the Continued Inpatient admission was medically necessary.

The patient is a female with a history of psychiatric illness who received inpatient psychiatric care.

The patient has a history of mental illness and has been diagnosed with bipolar disorder and borderline personality disorder.  She has been hospitalized at psychiatric facilities over ten times.  She has a history of polysubstance abuse and has been noncompliant with her medications.  She has a history of domestic abuse and is currently in an abusive relationship.  She has been homeless and living in tent.  She was recently drinking alcohol daily and using Suboxone that she was buying off the street.  There is a history of self-injurious behavior.

She reported worsening depression, poor energy/sleep/motivation.  She was medically cleared for inpatient psychiatric hospitalization and was admitted.  She was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  She received individual and group therapy.  She received a psychopharmacology evaluation and was treated with Seroquel that was increased to a total of 800mg per day, Prozac 40mg per day, and Gabapentin 400mg TID (three times daily).

The patient received multiple prn (as needed) medications for ongoing anxiety. The patient was discharged to outpatient psychiatric care.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression, anxiety, and substance abuse with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained with significant anxiety and need for prn medications.  The patient had multiple static risk factors for potentially dangerous behaviors, including prior self-injury and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors. Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, benign prostatic hyperplasia (BPH), asthma, and costochondritis (chest wall pain).  The patient presented to the hospital for evaluation of chest pain. The patient was mildly hypotensive at 94/64, which corrected with intravenous (IV) hydration in the ER. The electrocardiogram (ECG) revealed no acute ischemic changes. Cardiac troponins were negative. The patient had a recent nuclear stress test (two weeks prior to admission), which was reportedly normal, and he was diagnosed with chest wall pain. He was found to have low potassium of 3.2 and low calcium of 5.8 (patient is vegan), which were supplemented. He was treated with non-steroidal anti-inflammatory drugs (NSAIDs) for chest wall pain and was discharged from the hospital 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. No ischemic work-up was planned by the treating physicians, as patient had a recent nuclear stress test as outpatient. There was no plan for cardiac catheterization or computed tomography angiogram (CTA). The patient was treated with IV fluids, which corrected his tachycardia. Electrolytes were supplemented. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), or malignant arrhythmia. 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: Overturned

Diagnosis: Suicidal ideation 

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission.

The denial is reversed. 

This was then a female who was admitted to the hospital due to chest pain, depression, suicidal ideation and attempt to induce a heart attack by taking cocaine and large amounts of alcohol. The patient had stopped her psychotropic medications. On exam, the patient had depressed mood, feelings of hopelessness, helplessness, guilt, anhedonia, poor motivation, and had chest pain with diaphoresis and nausea. The patient's psychiatric history was significant for suicide attempts by overdose and cutting herself with a knife requiring sutures. It was reported that the patient was drinking multiple shots per day and using cocaine daily. The patient had a positive toxicology for benzodiazepines and cocaine. The patient was seen by Psychiatry who recommended 1:1 observation due to suicidality. The patient was noted to be agitated the next few days and continued to require 1:1 observation for suicide precautions. The patient was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk for suicide and also reports that patients with alcohol/substance use are at increased risk of suicide. This patient was at a high-risk for suicide as she presented with a suicide attempt and had a heavy daily use of alcohol and cocaine. The patient reported drinking multiple shots of alcohol per day and using cocaine daily. The patient had a psychiatric history of similar suicide attempts, and had diagnosis of Schizoaffective Disorder-Depressive Type but was noncompliant on medication. 

Notes reported that the patient had depressed mood, feelings of hopelessness, helplessness, guilt, anhedonia, and poor motivation in addition to her suicidal thoughts and attempt. Notes reported that the patient was very agitated, threw a chair and her telemonitor, and pulled out her med lock. Notes reported that the Psychiatry consult recommended 1:1 for suicidal precautions for the patient; the patient remained agitated and kept refusing medications and telemetry monitoring. 

Based on the review of the medical record and literature, inpatient admission was medically necessary due to this patient's high risk for self-harm. The patient presented to the hospital with suicidal ideation and suicidal attempt to induce a heart attack by taking cocaine and large amount of alcohol. The patient had active symptoms of chest pain, diaphoresis and nausea on presentation. The patient also reported clinical symptoms of depression and was non-compliant with her medications. And throughout the inpatient stay the patient was noted to be agitated and required 1:1 observation for suicidal precautions. 

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

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial should be reversed
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.  

The denial is reversed. 

The patient was then a male child with a history of asthma who had been on daily Flovent.  The patient had been running during a PACER test at school when he started to have chest tightness and shortness of breath.  The patient also had abdominal pain and cramping.  When his symptoms did not improve with 3 puffs of albuterol at school, the patient was taken by ambulance to the Emergency Room (ER).  In the ambulance, the patient received two treatments with albuterol and Atrovent and Solumedrol.

In the ER, the patient was noted to be in moderate respiratory distress with an increased respiratory rate of 35 and evidence of labored breathing.  The patient was also noted to have difficulty speaking because of shortness of breath.  On physical exam, the patient was noted to have expiratory wheezing.  The patient was also noted to be anxious.  The patient was treated with a bolus of intravenous (IV) normal saline, several doses of Atrovent and albuterol, magnesium sulfate, terbutaline and epinephrine.  The patient's blood testing demonstrated a respiratory alkalosis with a pH of 7.57 and a pCO2 of 20.  The patient's potassium level was low at 2.9 and his HCO3 was low at 16.  The patient's protime (PT) was elevated at 15.5.  The patient's electrocardiogram (EKG) showed borderline prolonged QT interval.  When his asthma did not improve completely with treatment in the ER and when his labs and EKG were noted to be abnormal, the decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with steroid, potassium and albuterol every 4 hours.  

Based on the review of the literature, the patient was treated appropriately in the ER for an exacerbation of asthma that did not respond to outpatient therapy.  It was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 4 hours for ongoing wheezing.  The patient had low potassium level and abnormal EKG that were concerning of cardiac arrhythmia. It was appropriate to admit the patient to safely treat and monitor these abnormal findings and ensure continuing therapy for his acute asthma episode.

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 inpatient hospital admission should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic fibroids
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission. 
The denial is reversed. 

Based on the review of the medical record, the patient was then a female with a history of symptomatic fibroids.  The patient underwent an open abdominal myomectomy.  The procedure was uncomplicated and the patient was discharged home.
Thought this patient's procedure was uncomplicated, this patient's procedure was a laparotomy rather than a laparoscopic procedure. While laparoscopic procedures are ambulatory, literature indicates that the standard of care for laparotomy or open procedure is inpatient stay for 48 hours. This is consistent with the Milliman Care Guidelines (MCG) for open abdominal myomectomy, which this patient received.  Thus, inpatient admission was medically necessary to treat this patient's medical condition.

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 inpatient admission should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe leg pain 

Treatment: Inpatient stay 

The insurer is denied coverage for inpatient stay. 
The denial is upheld. 

This was a female with several medical problems (status post bowel perforation and surgery, status post ORIF [open reduction with internal fixation] right fibular fracture). These procedures were completed after her admission. The patient had a complicated course. The patient was discharged to home and had an episode of a fall. Family could not assist the patient and an ambulance was called. The patient presented to the Emergency Department (ED) complaining of severe pain to the right leg. The patient was unable to ambulate and wanted to go to rehab. The patient had difficulties with managing her stoma. As per ED note, the decision was to admit the patient to Medicine because the patient was unable to stand and at risk for another fall. Records show that the patient was admitted. Imaging was completed and orthopedic consultation was obtained. She was discharged.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. There was no evidence of post-surgical complication to the patient's ankle or stoma. The patient's vital signs were stable. The patient was able to tolerate oral medications. The patient did not require medical treatment for other conditions. Recent imaging did not demonstrate a new finding to require management. Subspecialist consultations and therapy services could have been provided as outpatient or less intensive setting. There were no other factors present which could substantiate the length of stay.

The acute inpatient stay is not considered medically necessary for this patient.

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

The carrier's denial of coverage for the acute inpatient stay should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse
Treatment: Inpatient Substance Abuse Treatment 
The insurer denied the Inpatient Substance Abuse Treatment.
The health plan's determination is upheld. 

The patient is an adult male who was admitted to inpatient level services for detoxification of alcohol and stimulant class substances of abuse. The patient had been using up to one pint of liquor plus beer on a continuous daily basis, as well as two grams of crack cocaine and two grams of cocaine with intranasal administration (snorting). The patient reported no past history of withdrawal seizures or delirium tremens. His self-referral was prompted by a desire to stop using these substances and get his life in order. He presented with mild to moderate symptoms of withdrawal that included tremor, nausea and diarrhea, itching, anxiety and irritability. 

The Inpatient Substance Abuse Treatment 11/16/2019-11/21/2019 is not medically necessary for this patient.
The Inpatient Substance Abuse Treatment could have been safely and effectively provided with lower level services. The patient in this case was using alcohol on a continuous daily basis together with daily use of cocaine. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the patient had been discharged from detoxification treatment five days prior to admission and the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in a less restrictive treatment setting. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient level treatment in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria, NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, and scientific literature, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, inpatient level of care was not medically necessary. 

The patient is a male with a mediastinal mass and chest pain who was admitted to the hospital.

Observational level of care would have been appropriate for this patient. The patient was clinically stable and had non-cardiac chest pain that could be managed by analgesics. There was no acute, emergent condition identified that needed inpatient stay. The patient's respiratory status was stable and the patient was hemodynamically stable.  Management of his mediastinal mass could be done as an outpatient.  Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: SIRS/Sepsis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Stay.
The denial is upheld in whole. The inpatient hospital stay is not medically necessary.

This is the case of a patient with past medical history of diabetes, hyperlipidemia, coronary artery disease status post stenting, schizophrenia, and asthma, who presented to the hospital with a fever to 101F and body aches.
This patient  presented with fever, cough, mild tachycardia, and body aches with likely upper respiratory infection with chest x-ray unremarkable. The was noted to be comfortable on exam, with lungs clear, without hypoxia, and additionally had mild acute kidney injury. It is unclear why on presentation in the absence of respiratory distress, tachypnea, hypoxia, immunocompromising condition increasing his risk of adverse event or prolonged recovery, and with very mild acute kidney injury why this patient would have been unsafe to care for in a lower level of care with IV fluids, Azithromycin, Tamiflu and monitoring of his symptoms.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary.
Surgical Services  (All).

Diagnosis: pelvic congestion syndrome.
Treatment: Ovarian Vein Embolization.
The insurer denied the Ovarian Vein Embolization. The health plan's determination is overturned. 

The patient is a female who presents with symptoms of pelvic congestion syndrome. Her main symptoms include chronic pelvic pain, dyspareunia and urethral pain. Per the provider, her symptoms interfere with her activities of daily living. A computed tomography venogram demonstrated reflux in the left ovarian vein. She underwent selective catheterization and coil embolization of the left ovarian vein for treatment of her condition.

The Ovarian Vein Embolization performed is medically necessary for this patient. This particular patient is a good candidate for venogram and treatment of her refluxing gonadal and pelvic veins as listed below. This treatment is supported by the peer reviewed literature and is consistent with the current standard of care in the vascular surgery community. The patient presents with symptomatic pelvic pain and dyspareunia. Her presenting symptoms are indicative of possible pelvic congestion syndrome. The most recent consensus guidelines (2011) by the Society for Vascular Surgery and the American Venous Forum for the treatment of venous disorders support the use of ovarian vein embolization for the treatment of pelvic congestion syndrome based on the existing peer reviewed evidence.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hidradenitis suppurativa.
Treatment:  Inpatient Stay.
The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This case involves a female with a history of hidradenitis suppurativa, with prior history of surgical wound debridement, who presented to the hospital, as the surgical wound opened up.  She reported no fevers chills or significant pain.  The patient was taking ciprofloxacin on admission.  She has undergone multiple excisions of hidradenitis, in numerous body locations.

The inpatient hospital stay is not medically necessary for this patient.  This is a patient, who appears to have Hurley stage II hidradenitis suppurativa.  This is a chronic and recalcitrant condition that typically requires multiple excisional procedures.  In this presentation, the patient has a recurrence of a lesion in the left groin, as well as dehiscence of the wound, from a previously excised hidradenitis in the left inframammary region.  These were addressed surgically.  The operation was without complications, and the patient was discharged the following day.  This type of presentation is typically accomplished under a lower level of care.  There is no sign of systemic illness; there is no sepsis; and the patient is hemodynamically stable.  The intraoperative cultures showed coagulase-negative staph, which is a skin contaminant, and Proteus mirabilis.  The patient was appropriately covered with Cipro before coming into the hospital.  This patient did not require skin graft placement or wound vacuum-assisted closure (VAC).  As a result, the inpatient stay is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure
The insurer denied: Crown for tooth 20
The denial is: Upheld in whole

The patient is a female who presented to the office of her dental provider for evaluation and treatment of tooth #20 with a porcelain fused to high noble metal crown (2750). Included for review are previous letters of appeal and denial, full mouth radiographic images, and one page of American Dental Association (ADA) claim forms. In question is the medical necessity of the treatment of (2750) porcelain fused to high noble metal crown #20. The subject under review is the medical necessity of the crown.

The health plan's determination is upheld, in whole.

No, the requested service of crown for tooth 20 is not medically necessary for this patient. There is no decay present nor is there any documentation of decay or failure of the restoration provided by the treating dentist to support the treatment. There is no medical reason to remove the existing restoration and replace it with a new crown.
Hence, the treatment is not medically necessary.