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

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult female with a history of recurrent syncope that presented to the hospital with chief complaint of syncope. The patient reported feeling lightheadedness while walking into the patient's room. The patient also reported having chest pain prior to loss of consciousness.  Past medical history was significant for a recent hospital admission for syncope with negative work up, polycystic ovary syndrome, bipolar disorder, and hypothyroidism. Vital signs were stable on presentation and physical examination was without abnormality. No evidence of orthostatic hypotension was found. 12 lead electrocardiogram demonstrated sinus rhythm with normal conduction interval, no ectopy and no ischemic ST or T wave abnormalities. Serum blood testing demonstrated no abnormalities. The patient was admitted to the hospital. Neurology and Cardiac electrophysiology consultations were obtained. Magnetic resonance imaging (MRI) of the brain demonstrated no abnormality and a mobile telemetry monitor was recommended. The patient was discharged the following day with planned follow up.

This patient presented with syncope that occurred while standing. Symptoms were preceded by a period of lightheadedness. No significant cardiac findings were noted on serum blood testing, electrocardiogram (ECG) or echocardiography. The patient had a recent hospital admission for syncope that revealed no clear etiology for symptoms. According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality (1). In a study of individuals presenting to the emergency room, patients that were low risk for cardiac events (no significant cardiac history of acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing (2). In this case, the patient falls into a low-risk category and could have been managed at a lower level of care. Acute 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: Gvoke HypoPen 2 Pack 0.5 milligrams (mg) per 0.1 milliliters (ml) subcutaneous (SC) solution auto injector (SOAJ)
The insurer denied coverage for Gvoke HypoPen 2 Pack 0.5 mg per 0.1 ml SC SOAJ.
The denial is upheld. 

Glucagon is necessary for all patients on insulin. The patient has type 1 diabetes and is on insulin. There are no studies showing superiority of the requested medication over generic injectable glucagon [1, 2] or inhaled glucagon in the form of Baqsimi. The patient can use one of several formulations including inhaled Baqsimi. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for Gvoke HypoPen 2 Pack 0.5 milligrams (mg) per 0.1 milliliters (ml) subcutaneous (SC) solution auto injector (SOAJ) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Embolism
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is overturned.

The patient is an adult with morbid obesity and diabetes who presented to the emergency department (ED) with complaints of shortness of breath (SOB), fever, dry cough and right sided mid back pain. The patient had been hospitalized the previous week for viral pneumonia.

At presentation, the patient had a temperature 102.9 degrees Fahrenheit (F), respirations 30, blood pressure 125/74, pulse 139. The patient was diaphoretic and had some decreased breath sounds over the right lung fields along with some rhonchi.

White blood cell count (WBC) was 13.3 and Hemoglobin 10.1. The patient had a computed tomography (CT) angiogram which revealed right lower lobe (RLL) segmental/sub segmental pulmonary embolism (PE), sublobar RLL consolidation which was consistent with pulmonary infarct and a small right effusion. The patient was admitted for treatment of PE given morbid obesity, fevers and possible pneumonia; the patient was considered to be at high risk.

This patient continued to have fever over the next few days with temperature fluctuating between 103 degrees F (Fahrenheit) and 101.7 degrees F. The patient was tachycardic throughout. The patient was initially treated with intravenous (IV) Heparin and then continued on Lovenox. IV Rocephin was started for possible pneumonia along with oral (PO) Azithromycin. An echocardiogram did not reveal a right heart strain. Deep vein thrombosis (DVT) study was negative.

The patient continued to be febrile through the hospital stay. The patient was switched to PO Eliquis. The patient was febrile to 101.7 degrees F.

Given the multiple comorbidities and persistent fevers and tachycardia, it was safer to admit the patient in the hospital for treatment of the PE and pulmonary infarct. Pneumonia remained a possibility and the patient was treated for it.

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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bile Duct Disease
Treatment: Inpatient hospital stay
The insurer denied coverage for an inpatient hospital stay.
The denial is upheld.

The patient had a previous Whipple surgery for pancreatic cancer. The patient also was treated with chemotherapy and required a lung resection for a pulmonary nodule. The patient underwent radiation therapy. The patient had possible cholangitis and a stent was placed. The patient now presents with nausea and vomiting. The patient was afebrile, and the vital signs were stable. On exam, a percutaneous biliary drain was noted to be leaking. There were no peritoneal signs. A Computed Tomography scan showed vascular invasion and biliary duct dilatation. The alkaline phosphatase was elevated. The plan was for an exchange of the biliary drain by interventional radiology. The drain was exchanged. The patient spiked a fever and was given an antibiotic. There was no leukocytosis. The patient was discharged on oral antibiotics and the symptoms improved. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (MCG [Milliman Care Guidelines] M-555) include having acute cholangitis. This needs to be manifested by both systemic signs of inflammation and evidence of common bile duct disease. In this case, there was evidence of bile duct disease, but the patient did not have fever or leukocytosis (elevated white blood cell count) upon presentation. There was only a transient fever spike after the obstruction was relieved by the exchange procedure. The patient also did not have hemodynamic instability, severe vomiting, severe pain, severe dehydration, or bacteremia. The patient had biliary dilatation that was relieved by the exchange procedure. 

This patient required an exchange of the percutaneous biliary drain. The patient was not having evidence of acute cholangitis. The patient tolerated the procedure well and the symptoms were relieved. The patient did receive one unit of packed red blood cells (PRBC), but this could have been given as an outpatient. No complications were reported, and the patient was stable to have had the biliary drain exchange performed on an ambulatory basis. The patient could then have been discharged on a course of an oral antibiotics. The patient remained stable to have had an ambulatory procedure. An inpatient hospital stay was not medically necessary. The denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for an inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left ankle fracture and right sided transfemoral 
amputation
Treatment: Durable Medical Equipment: Wheelchair (K0823 
x1, K0108 x1)
The insurer denied: Durable Medical Equipment: Wheelchair (K0823 x1, K0108 x1)
The denial is overturned

The patient is an adult female with a medical history of peripheral vascular disease, hypertension, left ankle fracture and right sided transfemoral amputation last year. A wheelchair evaluation from four months ago indicated that the patient currently uses a standard manual wheelchair for mobility that is no longer functioning properly and is in need of replacement. The patient requires minimal assistance at times to complete slide board transfers. She is non-ambulatory and weight bearing as tolerated on her left lower extremity. The patient can propel a manual wheelchair household-distances but requires assistance for community mobility. She requires assistance with her daily activities. The patient has 5/5 motor strength in the upper extremities and 4/5 motor strength in the lower extremities except for below her right transfemoral amputation. The patient trialed a power wheelchair and a home accessibility evaluation was performed 2 months ago. The requested power wheelchair was considered not medically necessary. This decision is being appealed.

The requested power wheelchair is medically necessary.

The patient is an adult female with a medical history of peripheral vascular disease, hypertension, left ankle fracture and right sided transfemoral amputation last year. A wheelchair evaluation indicated that the patient currently uses a standard manual wheelchair for mobility that is no longer functioning properly and is in need of replacement. The patient requires minimal assistance at times to complete slide board transfers. 
She is non-ambulatory and weight bearing as tolerated on her left lower extremity. The patient can propel a manual wheelchair household-distances but requires assistance for community mobility. She requires assistance with her daily activities. The patient has 5/5 motor strength in the upper extremities and 4/5 motor strength in the lower extremities except for below her right transfemoral amputation. The patient trialed a power wheelchair and a home accessibility evaluation was performed. The patient cannot ambulate due to a transfemoral amputation and limited function of her contralateral limb due to prior ankle fracture. Therefore, she cannot use a cane or walker for mobility. She can propel a manual wheelchair for short or household distances but does not have the endurance to propel a wheelchair for community mobility. The patient cannot use a power scooter given that she requires assistance for transfers. She is documented to be able to use a power wheelchair and her home is accessible for a power wheelchair. She requires a power wheelchair for mobility and accomplishing her daily activities. The requested power wheelchair is a basic one and meets her basic mobility needs. It would be the most appropriate option given her mobility needs and given her medical conditions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excessive skin
Treatment: 15836; excision, excessive skin and subcutaneous tissue (includes lipectomy); right/left arm
The insurer denied coverage for 15836; excision, excessive skin and subcutaneous tissue (includes lipectomy); right/left arm
The denial is upheld.
 
According to the surgeon's letter the patient has chronic skin infections and inability to participate in physical activities due to excessive and redundant skin. The doctor indicates in a letter that the patient has required treatment for chronic rashes in her upper arm skin folds. Photos show a female with excess arm skin but rashes are not visible. Office visit treatment notes for rashes are not provided for review. A list of medications used to treat the rashes is not provided. According to the American Society of Plastic Surgery Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients"(1), "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." 

The records do not support any rare circumstances that mandate treatment with brachioplasties.  According to a 2010 outcome analysis of brachioplasty surgery, "Patients report improvement in contour and self-esteem, and a high level of satisfaction with this procedure, despite the potential for an unfavorable scar."  This study found improvements in self-esteem and contour but did not describe functional benefits from brachioplasty surgery. According to Sergesketter: "Brachioplasty has become one of the fastest-growing aesthetic surgery procedures, paralleling rising rates of weight loss surgery nationally."  The records do not confirm medical necessity for the proposed procedures. If they exist, office notes document treatment for rashes should be provided along with a list of medications used to treat the rashes. Finally, photos showing rashes should be provided to confirm medical necessity for this procedure that is generally performed for cosmetic indications. 

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 15836; excision, excessive skin and subcutaneous tissue (includes lipectomy); right/left arm is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Venous thromboembolism, chronic venous stasis ulcers, anemia, acute kidney injury
Treatment: Continued Inpatient Hospital Admission
The insurer denied: Continued Inpatient Hospital Admission
The denial is overturned

The patient is an adult female with morbid obesity, VTE (venous thromboembolism), and chronic venous stasis ulcers. She presented to the hospital with anemia and a two-week period of 
hematuria with supratherapeutic INR (international normalized ratio) and new onset AKI (acute kidney injury).
The patient was transfused with 5 units PRBC (packed red blood cells) and placed on IV (intravenous) antibiotics. She was hypoxic and placed on oxygen. She was seen by ID (infectious diseases) and vascular surgery, who had no recommendation. She underwent wound care for her venous ulcers. The patient's renal function deteriorated, and Lasix was adjusted. A CT (computed tomography) scan showed a cystic structure in the stomach, and she underwent EGD (esophagogastroduodenoscopy) with finding of a Schatzki ring. She was seen by PT (physical therapy) and recommended rehabilitation. Progress was made, and the patient was planned for discharge, but she tested positive for COVID. During this time, she had hypokalemia, requiring supplementation of potassium. She then became obstipated, requiring disimpaction and she had worsening hypoxia with increased oxygenation.

The Continued Inpatient Hospital Admission was medically necessary.

This patient required admission for her severe anemia requiring PRBCs (packed red blood cells) with an initial hemoglobin of under 7 in the setting of severe coagulopathy. Her initial hospital 
course was complicated by hypoxia, vascular wounds, AKI (acute kidney injury), dysphagia, and a stomach mass. She then developed hospital acquired Covid with hypoxia, which prevented discharge and placement. Therefore, the Continued Inpatient Hospital Admission was medically necessary, as it would not have been safe to discharge the patient or treat her at a lower level of care for the dates of service under review.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thrombocytopenia
Treatment: Inpatient Hospital Services
The insurer denied the inpatient hospital services.
The determination is overturned.

This is a patient with a history of hypertension (HTN), diabetes mellitus type 2 (DM II), and prior episodes of mild thrombocytopenia presented with fatigue. He had run a 5-kilometer (K) marathon several weeks before presentation. He was seen by his primary care physician (or provider) (PCP) who performed some blood work that revealed profound thrombocytopenia. He was subsequently sent to the emergency room (ER) for further evaluation. In emergency room (ER), he was hemodynamically stable but was found to have low platelets as above, hemoglobin (Hb) of 10.8 and white blood cell count (WBC) of 2.7. He also had a low Na (sodium) of 126. He was dehydrated on exam and was started on intravenous (IV) fluids. Hematology was consulted who recommended admission for an expeditious work up due to profound cytopenia and concern for acute leukemia and inpatient bone marrow biopsy was performed. His electrolytes improved on intravenous (IV) hydration. He was subsequently discharged with a plan to follow up with hematology. At issue is the medical necessity of an inpatient stay.

The request for inpatient stay was medically necessary and appropriate. This patient had new onset pancytopenia and a moderate degree of hyponatremia that needed inpatient evaluation, a bone marrow biopsy to rule out acute leukemia and slow correction of the hyponatremia.  He had significant new onset pancytopenia with profound thrombocytopenia. He had a history of pancytopenia. He needed an expedited work up. He had monocytosis that could be peripheral blasts masquerading as monocytes and could be acute leukemia [1]. This needed to be ruled out. Due to new onset cytopenia that was symptomatic causing fatigue, he needed an expedited bone marrow biopsy that could be achieved in the inpatient setting [2]. He had moderate hyponatremia. The chronicity of it was unclear. He needed evaluation, treatment and slow correction of the sodium (Na), that would have taken his length of stay (LOS) beyond a period of observation [3]. Overall, the care provided to the patient was appropriate for an inpatient level of care. The patient was not suitable for a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory syncytial virus (RSV) 
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient is a toddler with a history of a previous admission to the hospital for a respiratory syncytial virus (RSV). She had been sick with a cough for 2 days. She then developed a fever the day prior to admission. The mother decided to bring her to the emergency room (ER) when she was noted to be breathing fast.

In the ER she was noted to have a pulse oximeter reading of 98%. Mom indicated that she had been eating less but that her oral intake of liquids and urine output had been unchanged. On physical examination she was noted to be tachycardic at a rate of 160 and to have wheezing upon auscultation of the lungs. She was treated with 3 doses of nebulized DuoNeb and dexamethasone. A chest x-ray was obtained which showed peribronchial increased lung markings. Blood testing was significant for a c reactive protein (CRP) of 2.3 and a serum lactate level of 5.3. A urine specific gravity was 1.017. An electrocardiogram (EKG) demonstrated tachycardia and evidence of possible prolonged QT (interval on an EKG) syndrome. A respiratory viral panel was positive for RSV virus. She was started on intravenous (IV) fluids and the decision was made to admit her to the hospital for RSV virus, wheezing and tachycardia. The plan was to administer albuterol every (Q) 4 hours as needed (PRN). She was not administered an IV normal saline bolus in the ER but the fluid bolus was administered 7 hours after she arrived in the ER and her next albuterol nebulization treatment was administered 8 hours after transfer to the floor from the ER.

The patient was treated appropriately in the ER for a cough, fever, rapid breathing and wheezing. She has a history of 1 recent previous admission to the hospital for an RSV related illness. Her breathing improved with three doses of DuoNeb and dexamethasone. A venous blood gas was not tested to evaluate for acidosis and she was not administered a bolus of normal saline to assess improvement in her tachycardia and possible dehydration. The decision to admit her to the hospital for observation, IV fluids and albuterol PRN was not consistent with the standard of care. The presence of prolonged QT on the EKG is not an appropriate indication for admission to the hospital and she could have been followed up in 24- 48 hours by her pediatrician with appropriate referral for consultation with a Pediatric cardiologist if the tachycardia persisted. She was stable enough to be sent home.

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 site of service is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory failure.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
This patient is an adult with multiple medical issues; morbid obesity, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and obstructive sleep apnea (OSA). She presented to the hospital with worsening shortness of breath (SOB) and hypoxia. Vital signs at presentation were Temperature 99.6 degrees F, Blood pressure (BP) 145/101, Pulse 107, and Respirations 20. Oxygen saturation on room air was 84-86% and on a 4-liter nasal cannula it was 95%. The patient had partial pressure carbon dioxide (PCO2) of 65. D dimer was elevated so a computed tomography angiography (CTA) was also done and revealed a dilated pulmonary artery but no definite pulmonary embolism (PE); likely secondary to pulmonary hypertension (PHTN). Chest x-ray revealed pulmonary congestion.

This patent was admitted for hypercapnic and hypoxic respiratory failure, which was multifactorial, secondary to CHF, COPD, and OSA. The patient was treated with intravenous (IV) Lasix, bronchodilators, nebulizers and placed on bi-level positive airway pressure (BIPAP). 

The patient was compliant off and on with BIPAP and PCO2 increased to 84. The patient was somnolent and not easily arousable, the BIPAP was resumed and her PCO2 improved to 75. The patient was subsequently titrated down to nasal cannula.

This patient needed an acute inpatient stay for her multiple medical issues and presentation with hypercarbia and hypoxic respiratory failure, COPD and CHF. She could not have been managed at a lower level of care.

The patient was discharged on oral medications once stabilized.

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 the inpatient admission is substantiated.