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

Diagnosis: Substance Abuse, Abdominal Pain
Treatment:  Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

The patient is a male with a history of a seizure disorder, alcohol withdrawal, and polysubstance abuse, who presented to the emergency department (ED) for vomiting and abdominal pain. On presentation, the Clinical Institute Withdrawal Assessment (CIWA) score was 17. The review of systems was negative for additional symptoms.
The patient was afebrile. He was visibly agitated, tremulous and diaphoretic. The physical examination was unremarkable for positive findings. Laboratory evaluation demonstrated unremarkable clinical findings aside from mild electrolyte derangements.
The patient was admitted for alcohol and opioid use disorder. The patient was placed on CIWA and Clinical Opiate Withdrawal (COWs) protocol and was treated with intravenous (IV) Ativan, IV fluids, thiamine, folate and methadone. An ultrasound showed a diffuse fatty infiltration of the liver. The patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was medically necessary. The documentation supports admission for alcohol withdrawal. The Diagnostic and Statistical Manual of Mental Disorders defines alcohol withdrawal as 2 or more distinguishing symptoms which develop within several hours to days following a significant decrease in alcohol consumption after a prolonged period of heavy drinking. These symptoms include nausea or vomiting, autonomic hyperactivity, insomnia, increased anxiety and agitation, tremor, perceptual disturbances, and seizure. In this case, patient had vomiting, agitation and tremors. These are all active clinical signs that represent alcohol withdrawal which warranted inpatient admission for close monitoring and administration of the CIWA protocol. The patient also had opioid use which further complicated the clinical issues and warranted treatment for opioid withdrawals. Early discharge was made possible due to AMA departure.
The risks of worsening and severe withdrawal are usually dependent on the usual amount consumed, as well as duration of consumption. Patients who consume large amounts of alcohol on a regular basis, for long periods of time, are more likely to develop withdrawal requiring pharmacologic intervention and are at high risk for progression. Alcohol withdrawal delirium, commonly called delirium tremens (DTs), is a life-threatening complication of alcohol withdrawal and this occurs in approximately 3-5 percent (%) of patients hospitalized with withdrawal symptoms. Mortality rates in cases of delirium tremens (DTs) without intervention the rate can be as high as 20 percent (%), with death most commonly resultant from infection, cardiac arrhythmias, or respiratory collapse, and symptoms typically begin after 1-3 days of abstinence.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Nausea Vomiting and Diarrhea.
Treatment: Inpatient admission.

The insurer denied: Inpatient admission.  The denial is upheld.

The patient is an adult female. She presented emergently on with nausea / vomiting, chills, diarrhea, and lower abdominal pain / cramping. The patient reported excessive EtOH (alcohol) intake the night before. The past medical history was significant for obesity, EtOH (alcohol) use, and daily marijuana abuse. The patient reported to be menstruating. The patient's exam was remarkable for diffuse abdominal tenderness. Labs showed a WBC (white blood cell) count of 20.2, ANC (absolute neutrophil count) of 18.4, neutrophils of 90.7. The anion gap was 17, ethanol was 51.3, and lactate was 8.19. The patient had reported recent history of unprotected sex and dysuria. HCG (Human Chorionic Gonadotropin) was negative. U/A (urinalysis) noted protein, ketones, blood, nitrites, and bacteria. Chest X-ray was normal. Transabdominal / transvaginal ultrasound showed a 3.5-centimeter simple ovarian cyst. CT (computed tomography) abdomen / pelvis noted mural thickening of the colon. There was a large left adnexal cyst 4.8 centimeters x 3.5 centimeters. The patient was hypotensive at 102/56. The patient was treated with Zofran 4 milligrams IV (intravenous), Pepcid 20 milligrams intravenous, Reglan 10 milligrams intravenous, Toradol 30 milligrams intravenous, intravenous normal saline 1 liter bolus x 3 followed by 125 cubic centimeters per hour. Cipro and Flagyl were administered. The patient was admitted with colitis, leukocytosis, rule out pelvic inflammatory disease, lactic acidosis and elevated EtOH (alcohol) levels, binge drinking, rule out ovarian torsion, anemia, and UTI (urinary tract infection). Testing for gonorrhea and chlamydia were negative, urine toxicity screen was negative. The patient clinically improved, with resolution of dysuria, diarrhea, nausea, vomiting, and abdominal pain. Labs showed anemia with a hemoglobin Level of 10.9. Patient was cleared for discharge. The patient was admitted and then discharged the next day.

The inpatient admission was not medically necessary.

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needing intravenous fluid support) that persisted; and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure needed that could not have been performed on ambulatory basis.
Appeal type: Medical necessity
Decision: Upheld


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

This case involves a woman with type 2 diabetes, two weeks postpartum after cesarean section, who was evaluated in the emergency department with drainage from the incision site. The symptoms started several hours before the presentation. Her C-section postoperative course was unremarkable. The drainage is described as significantly large and yellow, with no fevers, flank, back, or abdominal pain. Blood glucose values were stable at home. Temperature was 37.1 C, blood pressure 136/85, and pulse rate 94. Examination showed no erythema or edema surrounding the surgical scar. There was a 1-2 centimeter (cm) dehiscence left of the midline, draining clear yellow fluid. 

The inpatient hospital admission was not medically necessary.
Based on the provided documentation, the patient was evaluated for drainage from the C-section wound, which ultimately was characterized as a seroma but treated empirically with antibiotics. The patient did not exhibit signs of sepsis. There were no intraperitoneal findings suggestive of widespread infection. Hemodynamics remained stable. The patient improved within 24 hours and was discharged by the 48-hour mark home with wound care-postoperative seromas usually take days to a couple of weeks after surgery. Collections of blood or serum in the wound may be asymptomatic or manifest as swelling, pain, and drainage. The diagnosis can usually be made by inspection and palpation of the wound.
Based on the clinical documentation, there was no indication for surgical debridement, gangrenous skin, or necrotizing fasciitis. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with multiple medical problems including acquired immunodeficiency syndrome (AIDS) and squamous cell cancer of the anus who presented to the emergency room with rectal pain, vomiting, and diarrhea.
In the emergency room, he had unremarkable vital signs. The physical examination was remarkable only for induration on either side of the "rectum". He was noted to have a hemoglobin of 5.8 grams per deciliter (g/dL). He was moderately thrombocytopenic. He had some mild electrolyte abnormalities. He was coronavirus disease (COVID) positive (+). Imaging was unremarkable for acute changes.
In the emergency room (ER), he was transfused 2 units of packed red blood cells (pRBCs), initiated on intravenous (IV) morphine, given Zosyn+doxycycline, and started on potassium.
The patient was admitted for inpatient care due to the patient being anemic and unable to tolerate oral intake. He was evaluated by general surgery but no intervention beyond sitz baths were recommended. He was evaluated by infectious disease who recommended droplet precautions. The patient ultimately refused treatment and elected to leave against medical advice (AMA). The patient was discharged  inpatient care is under review for medical necessity.
Inpatient hospital admission was not medically necessary for this patient.
He had diarrhea resulting in hypokalemia; this was likely due to his underlying comorbidities/treatments (including radiation for anal cancer). He was hemodynamically stable when he was evaluated in the emergency room and throughout this hospitalization; thereby implying that he was able to take in enough orally to offset losses. Potassium can be administered orally.
This patient had anemia (likely secondary to AIDS and cancer therapy). He was known to be anemic from prior hospitalizations and was transfused in the emergency room.
No other acute findings were recognized in the admitting histories by other physicians.
While hospitalized, the patient did not require surgery, interventional procedures, nor intensive nursing care. He remained hemodynamically stable and without a fever. He received supportive care only throughout his hospitalization. The services rendered did not require inpatient care and support for inpatient care in this scenario is not present in the peer-reviewed literature, Milliman Care Guidelines (MCG) Guidelines, national guidelines, nor in UpToDate. For these reasons, medical necessity for this admission cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy.
Treatment: Inpatient Hospital.

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

In this case, a young child with a history of recently diagnosed epilepsy presented a status post myotonic grand mal seizure that lasted for 15 minutes. She was recently started with home continuous electroencephalogram (EEG) monitoring. The parents state that she had a staring spell and loss of tone in her arm, dropping her spoon but was normal immediately after. At around noon, she became unresponsive for 15 minutes. The Emergency Medical Services (EMS) was called, and the patient was brought to the Emergency Department (ED). 

In the ED, she was noted for activity change. Blood Pressure (BP) was 125/65, pulse was 108, respirations were 25, and oxygen saturation was 99% (percent) on a non-rebreather mask. She appeared post-ictal, tired but moving all extremities, localized to noxious stimuli, and became progressively more awake around her time in the ED. Neurology recommended a one-time dose of Depakote intravenous (IV) and increasing the patient's twice-daily dose of Keppra. There were no reported seizures, and she was stable, with a pulse rate of 123. 

Although the patient's pulse was 108, and there was an order to increase her Keppra, the care rendered is more appropriate at a lower level of care, such as observation care, to initiate dose adjustment. Admission is medically necessary when there is Febrile seizure, Status epilepticus, Brain disorder, altered mental status (i.e., different from baseline) that is severe or persistent, New focal neurologic deficit, Metabolic disorder, Recurrent seizure, Cerebral bleeding, hydrocephalus, or vasospasm monitoring, Increased intracranial pressure or cerebral edema monitoring, or an Outpatient antiepileptic regimen cannot be established. As such, the denial of coverage for the full hospital admission is upheld and is considered not medically necessary.

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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history of human immunodeficiency virus (HIV), hypertension, active smoking, chronic obstructive pulmonary disease (COPD), coronary artery disease status post percutaneous coronary intervention (PCI), and polysubstance abuse, who presented to the emergency department (ED) for evaluation of chest pain. The patient's calculated HEART [history, electrocardiogram (EKG), age, risk factors, troponin] score was moderately elevated. A chest x-ray (CXR) was clear. The EKG was negative for ischemic changes and the high sensitivity (HS) cardiac troponin was normal. The patient was admitted to the telemetry service under an inpatient level of care for evaluation of chest pain and rule out acute coronary syndrome (ACS). A urine drug screen (UDS) was positive for benzodiazepines and amphetamines. A stress test was recommended but the patient left the hospital against medical advice (AMA). At issue is the medical necessity of an inpatient stay.
Inpatient level of care was not medically necessary in this case. The patient presented to the emergency department (ED) with chest pain. An EKG was nonischemic and cardiac troponins were negative. The patient remained hemodynamically stable. According to the well-validated HEART pathway and the 2022 American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department, inpatient level of care was not medically necessary in this case due to the above factors (1-3). Rather, a lower level of care would have been medically appropriate and safe for evaluation of chest pain and completion of an ischemic evaluation prior to discharge.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male who presented with right foot pain and was referred to the emergency department (ED) for admission and surgical intervention following an earlier visit to the clinic. Two days prior, the patient had seen a podiatrist at urgent care who shaved a painful callus in his right plantar arch, noting it was infected.

The inpatient hospital admission was medically necessary. The decision for admission at the acute inpatient level of care was appropriate based on the specific circumstances surrounding the patient's case. Typically, admission at this level is deemed appropriate for individuals with soft tissue infections necessitating surgical procedures that are not amenable to outpatient or emergency department care. A thorough review of the patient's medical records revealed that he underwent an excisional biopsy of the right foot wound, along with irrigation and debridement. Considering the deteriorating symptoms, the potential requirement for intravenous antibiotic administration, and the need for close monitoring of the wound, it is evident that performing such a procedure on an outpatient basis would have been impractical. Additionally, the patient had previously taken oral antibiotics for seven days without experiencing any improvement in his symptoms, further emphasizing the necessity of the inpatient level of care to address the complexity of services provided and ensure a timely response to his medical needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces, monthly visits and retainer
The insurer denied braces, monthly visits and retainer.
The determination is overturned.

The patient is a female with impacted tooth number (#) 29. She has a 3 millimeter (mm) overjet and 5 mm overbite. Teeth 6 and 11 are blocked out to the labial. She is treatment planned for 24 months of orthodontics to address the crowding and to create space to bring the impacted tooth into the arch. At issue is the medical necessity of braces, monthly visits and retainer.

Approximately 10 percent (%) of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. (2) The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. (2) The panoramic radiograph for this patient appears to indicate a high chance that tooth 29 will damage the root of tooth 28 without treatment. If left untreated the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent Caries

Treatment: White glass with high gold content crown for tooth 5

The insurer denied coverage for white glass with high gold content crown for tooth 5.  The denial is overturned.

Based on the submitted documentation, which includes copies of bitewing and periapical radiographs, narrative letter from the patient, narrative letter from the dentist, narrative letter, 4 intraoral clinical photos and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was completed in the past on # (number) 5 with full coverage crown. Recurrent caries was identified, and replacement crown was recommended. The insurer has denied the full coverage crown, stating that the service is not medically necessary, as the documentation did not demonstrate medical need, and what is provided does not meet their medical necessity criteria. 

Upon review of the clinical and radiographic documentation, these support the recommended treatment. Review of radiographs indicates successful endodontic therapy on #5 with recurrent caries. There is ample coronal structure remaining on this tooth after the endodontic therapy and caries removal for support of crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be replacement of crown on endodontically treated teeth with recurrent caries, which would have an excellent long-term prognosis with the recommended treatment. As the clinical and radiographic findings support the recommended treatment the full coverage crown on #5 is considered medically necessary.

Reverse denial and approve coverage for white glass with high gold content crown for tooth 5 as medically necessary, as the clinical and radiographic documentation supports this service, which would be a standard of care in general dental practice.

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

White glass with high gold content crown for tooth 5 is considered medically necessary for this patient.

Based on the above, the insurer's denial must be reversed. 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 a white glass with high gold content crown for tooth 5 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cerebral palsy

Treatment: Cubby Plus Safety Bed

The insurer denied coverage for Cubby Plus Safety Bed

The denial is upheld

 
This case involves a young child with cerebral palsy, delayed developmental milestones, epilepsy with both generalized and focal features intractable, Esotropia, global developmental delay, myoclonic absence epilepsy, periventricular leukomalacia, transient motor tic, and related intellectual disability. Current medications include Melatonin, Prilosec, Albuterol, Depakote 125 milligrams (mg), Keppra 100 mg, Vitamin B-6, Carnitor, Atarax 10 mg, Senna. 

The patient was seen via telehealth. Falling asleep is easy but staying asleep is hard. Presently the patient's seizures remain well-controlled with 1-2 brief myoclonic seizures per day. It has improved with last Keppra increase. The patient is unable to call for help or communicate their wants and needs due to their expressive communication delays. The patient is getting too tall for their standard pediatric crib with slats and is often stuck sideways. Pillows, siderails, and padding have been attempted but can all be entrapment risks. They have used a pack 'n play, but the patient no longer fits because they are too tall. The patient has been struggling with sleep since they were 15-16 months old. The patient continues to have trouble falling asleep and staying asleep. The patient's bed mobility is considered a safety risk and cannot be accommodated by other pediatric hospital beds. 

The cubby bed comes with a canopy, mattress, two safety sheets, circadian light, speaker, and Microphone with two-way audio, camera, and cell phone applications. The securable mesh and fabric doors provide protection against wandering and falls. The zipper allows easy access to the patient in case of emergency such as a seizure.

There is no documentation that the patient has absconded from bed or that the patient requires an enclosure for safety. There is no documentation that the patient has had an injury while in bed, more than standing in their crib. It is unclear why the mattress on the floor was not adequate, as there is no documentation of concern for seizure risk while in bed, neurology notes well-controlled, occur twice daily and are brief. Circadian lights, speaker, and microphone with a 2 way audio and camera are not medically necessary and can be met with less costly alternatives including a baby monitor. 

The review of clinical, plan language, and literature found no documented evidence to support the need for a Cubby Bed. There are multiple alternatives available to include a low-to-floor mattress, soft padding surrounds, soft padding on the floor, bed enclosures, camera/monitor, bed exit alarms, soothing speakers. The decision to deny coverage for a Cubby Bed is upheld.

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 Cubby Plus Safety Bed is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Swelling 
Treatment: Inpatient Hospital Admission

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

The patient is a school-aged male with a history of swelling of the right neck with cough and nasal congestion. Right neck swelling had been present for one week on presentation to the emergency department. White blood cell count was 20.7, temperature was 99.6 (degrees) Fahrenheit (F), and vital signs were stable. Bilateral cervical lymphadenopathy was noted on the exam and ultrasound. The patient received intravenous antibiotics and intravenous fluids. Testing was positive for parainfluenza. The patient was admitted as an inpatient. The request was previously denied, and the provider is appealing the denial.

The requested health service was not medically necessary.

All records were reviewed. The patient was admitted for bilateral cervical lymphadenitis with a positive parainfluenza test. There was no documentation of airway obstruction. The patient was tolerating oral intake, and the pain was not uncontrolled. The patient responded to intravenous antibiotics and intravenous fluids, and no complications were noted. There were no documented abscesses. Therefore, based on the information provided, the medical necessity of the inpatient care for dates of service under review is not confirmed, as the patient's care did not require inpatient status. Therefore, the requested health service was not medically necessary.