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

Diagnosis: Shortness of breath

Treatment: Inpatient hospital admission 

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

This is a patient with history of (H/O) diabetes mellitus (DM), cardiovascular accident (CVA), residual hemiparesis, nephrolithiasis, and obstructive sleep apnea (OSA). The patient had been in a MVA (motor vehicle accident) and had sustained a L (left) Fibular Fx (fracture).

The patient presented to the emergency department (ED) with complaint of (C/O) some worsening LLE (left lower extremity) pain, Pleuritic chest pain (CP), shortness of breath (SOB) and R (right) flank Pain.

Vital signs (V/S) at presentation were Temperature 98.5F (Fahrenheit), Heart Rate 72, Respiratory Rate 17, Blood Pressure 120/70 mm Hg (millimeters of mercury), oxygen (O2) saturations 98% (percent) on Room Air. The patient was in no acute distress (NAD). Lungs were clear. Cardiovascular system (CVS) S1 (heart sound) S2 (heart sound) was N (normal sinus rhythm). There was a splint to the LLE. 

The patient had a white blood cell count (WBC) of 5.3K (thousand). Electrolytes were within normal limits as was the BUN (blood urea nitrogen)/Creatinine. The D Dimer (protein fragment) was elevated to 1149. The Troponin was normal.

The chest x-rays revealed (CXR) No acute infiltrates.

The patient was admitted to rule out (R/O) a pulmonary embolism (PE).

This patient had a H/O severe contrast allergy in the past so deep vein thrombosis (DVT) and VQ (Ventilation Perfusion) scan were planned. The patient was placed on Lovenox in the interim. As per MD (medical doctor) note, the patient had low probability of PE with a Wells score < (less than) 4.

The patient remained stable after admission. Afebrile and hemodynamically (HD) stable. Not hypoxic with no evidence of right heart strain on an EKG (electrocardiogram). Troponin was WNL (within normal limits). The patient's DVT study was negative. The patient was switched to oral (PO) Eliquis. The VQ scan was also negative for PE.

Eliquis was discontinued.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing to R/O a PE was done.

The patient was afebrile, hemodynamically stable, not hypoxic with a low probability for a PE. The patient remained stable after admission and was discharged home on PO meds. A PE could have been R/O while the patient was under observation status and the patient could have been discharged home once the PE was R/O.

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:  Epididymo-orchitis.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

The patient has a past medical history (PMH) of morbid obesity and hypertension (HTN) who was admitted with complaints of (c/o) left scrotal pain and swelling. Vital signs were notable for a maximum temperature (Tmax) of 101.6. degrees Fahrenheit. The physical exam was notable for left testicular tenderness and swelling. Lab work was notable for leukocytosis, urinalysis (UA) with pyuria, a urine culture positive for Escherichia (E)-coli, creatinine of 1.82. Imaging studies, a scrotal ultrasound (US) showed findings consistent with (c/w) left epididymo-orchitis. The patient was diagnosed with epididymo-orchitis and treated with intravenous fluids (IVF) and IV (intravenous) antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) scrotal swelling and tenderness associated with a fever. The ultrasound (US) showed findings consistent with left epididymo-orchitis and this was confirmed by specialty consultation. Given the patient's septic presentation, this patient met sepsis criteria, and the expected length of stay was greater than 48 hours. In addition, the infection was present in a high-risk location (genitals) that required a close level of monitoring that was not appropriate for a lower level of care. Overall, this systemically ill patient presented with left epididymo-orchitis complicated by severe acute kidney injury and required immediate treatment for the infection with intravenous antibiotics, aggressive IVF hydration, and expert consultation, and an inpatient level of care was required for safe medical evaluation and treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who presented to the emergency department (ED) with shortness of breath and wheezing. He was sent to the ED by his primary care physician (PCP).
ED vitals were heart rate (HR) 146, respiratory rate (RR) 24, oxygen (O2) saturation was 96% room air.
Physical exam notable for retractions. Positive respiratory syncytial virus (RSV) on respiratory panel. The patient was treated with intramuscular (IM) Decadron in the ED and was ready for discharge except began to have rebound retraction. Admitted for overnight observation and management of bronchiolitis, the patient was discharged home the next day.
At issue is whether the inpatient stay is medically necessary.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient with stable vital signs and no oxygen requirement. With minimal symptoms post-ED management, treatment at a lower level of care would be most appropriate.
The patient is an otherwise healthy male with mild RSV bronchiolitis. He had stable, normal vital signs in the ED and responded well to treatment with IM Decadron. The patient was to be discharged home, but overnight monitoring was decided based on rebound of symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal- Back Pain
Treatment: Inpatient Hospital stay
The health plan denied the inpatient admission as not medically necessary. 
The reviewer has upheld the determination in whole. 

This case involves a patient with gastroesophageal reflux disease (GERD) and fibroids who presented to the emergency department (ED) with intractable lower back pain. The pain radiated into her abdomen. She denied any trauma or lifting any heavy things. The pain started suddenly at rest and was described as constant and sharp. Naproxen and Tylenol proved to be unreliable in relieving the pain. The pain was most exacerbated when changing positions from a standing to a sitting and laying down position. The current pain was different from her chronic pelvic pain with menstrual cycles.
On exam, the patient appeared to be in no acute distress, with a normal cardiopulmonary exam. Neurologically the patient was intact. An abdominal exam revealed no rigidity or tenderness. Strength in the upper extremities was 4 out of 5, and 3 out of 5 in the bilateral lower extremities, with a slow antalgic gait.
Imaging of the lumbar spine showed no abnormality. A computed tomography (CT) scan of the abdomen and pelvis without contrast showed no acute intra-abdominal or pelvic process. Labs were unremarkable. The patient was given intramuscular (IM) Toradol, Flexeril, Percocet, and Diazepam in the emergency department and admitted to the hospital under the medicine service. The medical team scheduled the patient on methocarbamol, Tylenol, ibuprofen, and Percocet. Physical therapy was consulted for an assessment. The patient's home medications were continued.
The next day, the patient was reassessed and noted that her pain had improved by half. The medical team documented no radiation of the pain, and they stated the patient could ambulate. As a result, the patient was discharged home with outpatient physical therapy (PT) and follow-up with her primary care physician.

Inpatient admission is not warranted in this case. Based on the provided documentation, the patient presented to the hospital with new onset of low back pain, which could not be relieved in the emergency department. Therefore, the patient was admitted for pain management. Within 24 hours of hospitalization, pain control was improved with oral anti-inflammatory, as-needed narcotic, and muscle relaxant medications. The medical team documented the pain had decreased from 10 out of 10 to 5 out of 10, and the patient could ambulate, and was looking comfortable. Therefore, there is no evidence of a failure of a lower level of care, and hence no acute need for inpatient level of care. In addition, the imaging studies failed to demonstrate any significant pathology to warrant an inpatient level of care. There is no evidence of spinal infection, intra-abdominal infection, impacted kidney stone, or bowel obstruction, all of which produce low back pain symptoms. The patient did not have bowel or bladder function loss to worry about a degenerative neurologic process. There is no inpatient admission diagnosis to support the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rib fractures
Treatment: Hospital admission
The insurer denied the hospital admission.
The health plan's determination is upheld.

The patient is a female status post (s/p) fall while a riding mountain bike who presents to the emergency department complaining of right chest wall pain. She was wearing a helmet. She denies any loss of consciousness. Pain is worse with deep inspiration. Physical exam shows wheezing on the right side. The remainder of the physical exam was unremarkable. Laboratory studies were normal. A computed tomography (CT) chest showed non-displaced rib fractures 5- 9, 0.9 adrenal nodule and right trace pneumothorax. The remainder of the CT scans were negative for injuries. She was admitted to the trauma service.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented s/p fall while riding a mountain bike complaining of right sided chest wall pain. She was found to have 4 nondisplaced right rib fractures and trace right pneumothorax. She did not require a chest tube for her right pneumothorax. She was admitted for pain control and surveillance of her pneumothorax. The patient's care could have been given at a lower level of care. The patient did not require any intravenous (IV) narcotics. She did not require any chest tube placement. She did not require any surgery nor intubation. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease/GERD.
Treatment: Inpatient Hospital Admission.
The health plan denied the inpatient hospital admission.
The health plan's determination is overturned.

This patient is a male with a past medical history significant for coronary artery disease (CAD) status post coronary artery bypass graft (CABG), hypertension (HTN), and hyperlipidemia who presented with right upper quadrant (RUQ) pain for 1 day. The patient had an elevated white blood cell count (WBC) of 16.8 and hyperbilirubinemia of 3.6. An ultrasound revealed cholelithiasis and a dilated gallbladder. A computed tomography (CT) scan of the abdomen was consistent with acute cholecystitis. His bilirubin and WBC worsened on hospital day#2. Given the findings of hyperbilirubinemia with possible choledocholithiasis, the patient was admitted and made nothing by mouth (NPO) with intravenous fluids (IVF) and he underwent a magnetic resonance cholangiopancreatography (MRCP). On hospital day #3 it was felt that the hyperbilirubinemia was not related to gallstones but possibly Gilbert's disease. Cardiology clearance was obtained. The patient underwent laparoscopic cholecystectomy with the placement of a Jackson-Pratt (JP) drain. On postoperative day (POD) #1 the patient had serosanguinous drainage from the JP, stable vital signs, improvement of liver function tests (LFTs), and was started on liquids. On POD #2 the patient was advanced to a regular diet which was tolerated, and he was discharged home with a JP drain.
At issue is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is overturned, on whole. 

Although admissions for elective cholelithiasis are often able to be treated at an ambulatory or observation level of care, this patient presented with findings of acute cholecystitis, leukocytosis, and hyperbilirubinemia with a history of CAD post-status CABG. Given the findings, the patient required a gastroenterology consultation to rule out choledocholithiasis and obtain cardiac clearance for possible surgery. During this period, the patient required NPO status, IVF, and intravenous (IV) antibiotics. A decision was made to proceed with surgery on hospital day#4 and the patient was discharged home with the improvement of WBC, LFTs, and his ability to tolerate oral intake with pain controlled on POD #2. This could not have been treated at an alternate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unresponsiveness; full body tremors.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is overturned.

The patient is an adult male who presented to the emergency room with an episode of unresponsiveness and full-body tremors. This was in the setting of a nap.
Upon arrival, the patient was altered and not following commands. He was noted to have to shake in all extremities. There was also an episode of projectile vomiting. Workup including a video EEG (electroencephalogram) showed right frontal sharps and possible left temporal sharps but no seizure activity. MRI (magnetic resonance imaging) of the brain did not show any acute abnormalities.
The inpatient hospitalization was denied coverage by the health plan, as it was deemed not medically necessary. The denial is being appealed.

The Inpatient admission was medically necessary.
The patient was unresponsive and shaking, raising suspicion of status epilepticus. Status epilepticus is a condition that involves s seizures lasting for more than five minutes. Given the suspicion of this, inpatient admission was warranted for continuous monitoring as well as a video EEG (electroencephalogram) to rule out status epilepticus. Furthermore, MCG (Milliman Care Guidelines) guidelines 25th edition notes that admission would be necessary if EEG (electroencephalogram) was unable to be performed effectively and efficiently in the outpatient setting, which was the case in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Cord Injury
Treatment: Power Wheelchair
The insurer denied: Power Wheelchair
The denial is: Overturned

This is a female with incomplete cervical (C)2 spinal cord injury from birth who is wheelchair dependent. She currently functions with a 6-year-old power chair. She is tracked with nighttime mechanical ventilation. She has a fixed cervical lordosis which pushes her into a flexed posture. She has been denied an M3 Permobil power chair. The subject under review is the medical necessity for the power wheelchair.

The health plan's determination is overturned. 

The M3 Permobil power chair with power recline, tilt, and elevation is necessary for this patient. She requires power recline and tilts to relieve pressure on her back, sacrum, and limbs as she is at high risk for skin breakdown with osteomyelitis. She is also spastic and requires power recline and tilt to assume postures that minimize spasticity. A shock-absorbing base is also necessary to reduce the activation of tone. The tilting assists with clearing secretions that if aspirated will cause pneumonia or sepsis. An elevating seat allows her to reach a table for meals and activities of daily living. Due to limb weakness and spasticity, she requires control for the chair to be accessed through the joystick. With power mobility, power seating, and joystick controls this patient has maximal function and independence.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurativa
Treatment: Humira
The insurer denied: Humira
The denial is overturned

The patient is an adult male with hidradenitis, treated with oral and topical antibiotics.  The provider is requesting Humira.  The health plan requires use of topical and oral therapy as well as acitretin.

The proposed treatment is medically necessary.
The patient has tried and failed appropriate therapy and has significant disease.  Acitretin and retinoids are not as effective for hidradenitis suppurativa (HS) as Humira.

PIONEER II evaluated the efficacy and safety of adalimumab in 326 patients; the study design was the same as PIONEER I. Results from PIONEER II found that at 12 weeks, patients with moderate to severe hidradenitis suppurativa (HS) treated with adalimumab 40 milligrams weekly (beginning at week four after adalimumab 160 milligrams at week zero and 80 milligrams at week two), achieved a statistically significant greater clinical response than patients who received placebo (58.9% versus 27.6%, P <.001). Response was defined as improvement of hidradenitis suppurativa (HS)-related abscesses and inflammatory nodules at 12 weeks using the Hidradenitis Suppurativa Clinical Response (HiSCR) measure. The most common adverse events observed in PIONEER II with adalimumab versus placebo were headache (12.9% versus 12.9%) and exacerbation of hidradenitis suppurativa (HS) (4.3% versus 12.9%).  The two phase III studies (PIONEER I and PIONEER II) demonstrated that hidradenitis suppurativa (HS) patients achieved a statistically significant greater clinical response than patients who received placebo (58.9% versus 27.6%, P <.001).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ear/Nose/Throat - eustachian tube dysfunction.
Treatment: Surgical Services /Eustachian tube balloon dilation.
The insurer denied Eustachian tube balloon dilation.
The denial is upheld. 

The patient is a male with eustachian tube dysfunction. His symptoms include ear pressure. Medical management has included nasal steroids. The exam revealed retracted ear drums bilaterally. Hearing tests including a tympanogram was normal. The provider has recommended eustachian tube dilatation.
At issue is the medical necessity of Eustachian tube balloon dilation.

The health plan's determination of medical necessity is upheld as a whole.

No, the requested health service/treatment of Eustachian tube balloon dilation is not medically necessary for this patient.
There is a lack of well-designed, non-heterogenous studies demonstrating the long-term benefit of eustachian tube dilatation in patients with eustachian tube dysfunction with normal tympanogram. Although balloon dilatation of the Eustachian tube provides exciting research for chronic eustachian tube dysfunction, the literature does not support long-term effectiveness. The current literature is based on non-controlled case series with poor standardization. Recent 12-month studies showed a 50-60% improvement rate in symptoms and tympanogram data (Poe and Anand), yet these studies are prone to bias as there were few patients left in the control arm. Although the procedure is safe, there is no strong, high-quality evidence that this procedure is effective. A recent systemic review concluded, "Due to the limited and poor-quality evidence it is inappropriate to make conclusions on the effectiveness of any intervention; the evidence base is insufficient to guide recommendations for a trial of any particular intervention. Consensus on diagnostic criteria for Eustachian tube dysfunction is required to inform inclusion criteria of future trials." (Norman).
The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) recently released a clinical consensus statement. This document stated, "Consequently, the panel ultimately could not reach consensus regarding the overall short-term or long-term effectiveness of balloon dilation of the eustachian tube (BDET)."
Therefore, the requested health service/treatment of Eustachian tube balloon dilation is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episode.
Treatment: Inpatient Stay.
The insurer denied: Inpatient Stay.
The denial is: Upheld.

The patient is a female with a past medical history significant for hypertension, obstructive sleep apnea, diabetes mellitus, obesity, gastric bypass surgery, anxiety, depression, and a previous motor vehicle accident that resulted in cervical and lumbar radiculopathy and left-sided hemiparesis. She presented to the hospital after a syncopal episode and unwitnessed fall.

On the day of admission, the patient woke up with slight lightheadedness and frontal headache after having four episodes of watery, non-bloody diarrhea. She was walking in her apartment when she started experiencing blurry vision, and then woke up on the floor after an unwitnessed fall. The duration of loss of consciousness was unclear. There was no urinary or bowel incontinence, tongue biting, or postictal confusion reported. The patient was admitted with syncope that was thought to be vasovagal, headache, hyperkalemia, and diarrhea that resolved by the time the patient was admitted. Other clinical diagnoses included hypertension, diabetes mellitus, anxiety, and depression.
It was noted that the patient had tested positive for orthostatic hypotension. This was treated with an infusion of intravenous fluids. The echocardiogram was normal.
During the hospital stay, the patient remained in stable clinical condition and was transitioned to outpatient care the following day after admission.
The subject under review is the medical necessity for an inpatient stay.
The patient was admitted with syncope that was thought to be vasovagal, headache, hyperkalemia, and diarrhea that resolved by the time the patient was admitted. Other clinical diagnoses included hypertension, diabetes mellitus, anxiety, and depression.
It was noted that the patient had tested positive for orthostatic hypotension. This was treated with an infusion of intravenous fluids. The echocardiogram was normal.
During the hospital stay, the patient remained in stable clinical condition and was transitioned to outpatient care the following day after admission.

The health plan's determination of medical necessity is upheld as a whole.