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

Diagnosis: Rectal Prolapse.
Treatment: Inpatient Hospital.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient had a recurrent full thickness rectal prolapse and past medical history significant for Crohn's disease, kidney stones, bipolar disorder, and depression and a past surgical history significant for a partial colectomy as well as suture rectopexy. She was brought to the operating room for a robotic ventral mesh rectopexy and flexible sigmoidoscopy as management for a recurrent full thickness rectal prolapse. She tolerated the procedure well without complications. She was admitted at the inpatient level of care and felt stable for discharge on postoperative day #1. At issue is whether the inpatient level of care was medically necessary.
The inpatient stay was not medically necessary. The patient underwent a robotic ventral mesh rectopexy and flexible sigmoidoscopy and tolerated the procedure well. The patient is a young female without any severe comorbidities and there were no complications after surgery that required an inpatient level of care. The care provided after the robotic ventral mesh rectopexy (e.g. diet advancement, pain control) could have provided at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. Treatment: Inpatient Hospital. The insurer denied inpatient stay. The denial is upheld in whole.

The patient is a male with no past medical history who presented to the emergency department with a painful rash on his inner thighs and scrotum. He had been seen at urgent care the week prior and given ketoconazole cream and nystatin but subsequently had worsening of rash prompting his emergency department visit. He denied fevers, chills, nausea, vomiting, abdominal pain, dysuria, and penile discharge.

On presentation to the emergency department, he was afebrile with blood pressure 115/56, heart rate 102, respiratory rate 18, and with oxygen saturation 97% on room air. Exam otherwise noted a wet rash of the inner thighs with raw erythema and possible minor rash on the penis with no vesicles present. Computed tomography (CT) of the abdomen and pelvis showed enlarge bilateral inguinal lymph nodes without any concern for abscess or Fournier's. Scrotal ultrasound with Doppler showed no evidence of testicular torsion or epididymo-orchitis. In the emergency department, he was given intravenous (IV) vancomycin and plans for following up blood cultures, urology, general surgery and infectious disease consultations.

Urology and general surgery saw the patient with assessment that he did not require any surgical interventions and was stable for discharge from their perspective. Additional information was obtained that he had a habit of wearing tight clothing and working out and sweating without showering promptly afterwards.

He remained hemodynamically stable. His rash was improving. He was seen by infectious disease with assessment that he had likely folliculitis with perineal staph or strep infection that was likely impetigo and not consistent with herpes, and with recommendation to proceed with cefazolin and clindamycin and transition to oral Keflex and doxycycline for 10-14 days at discharge. Dermatology saw the patient with assessment that he likely had folliculitis with recommendations for Hibiclens wash as well as clindamycin gel. He was subsequently deemed stable for discharge. The subject under review is the medical necessity for the inpatient stay. 

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

This is a patient who presented with concern for folliculitis. He was hemodynamically stable, had not failed oral antibiotics as an outpatient, had no imaging evidence concerning for Fournier's or abscess, and did not have immunocompromise with uncontrolled diabetes or another condition anticipated to complicate recovery. After initiation of antibiotics, he improved quickly with vital signs remaining stable and without leukocytosis. Give this, and with it noted that folliculitis is a diagnosis that can almost always be treated without need for inpatient setting, this patient would have been safe to treat at a lower level of care status. Inpatient care was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea (OSA) 
Treatment: Hypoglossal Nerve Stimulation (64568 x 1, 0466T x 1) 

The insurer is denied coverage for Hypoglossal Nerve Stimulation (64568 x 1, 0466T x 1). The denial is overturned. 

This is a male patient with a history of history of obstructive sleep apnea (OSA), hypertension, high cholesterol, chronic insomnia, depression, gastroesophageal reflux disease with esophagitis and nonalcoholic steatohepatitis. It was reported that he failed continuous positive airway pressure (CPAP). Hypoglossal nerve stimulation has been advised. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Upper-airway stimulation (UAS) has been shown to lead to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea (OSA) [references 1-6]. 

The Hypoglossal Nerve Stimulation (64568 x 1, 0466T x 1) has final approval from the appropriate regulatory bodies for this diagnosis. It was approved by the FDA in 2014 [reference 7] to treat a subset of patients with moderate to severe OSA (apnea-hypopnea Index [AHI] of 20 to 65). Inspire UAS is used in adult patients 22 years of age and older who have been confirmed to fail or cannot tolerate CPAP or BPAP machines and who do not have a complete concentric collapse at the soft palate level. 

This patient is a good candidate for Hypoglossal Nerve Stimulation (64568 x 1, 0466T x 1). UAS has been shown to be a non-anatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure [references 1-6]. In a Position Statement [reference 8] the American Academy of Otolaryngology-Head and Neck Surgery stated that it "considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy." 

Thus, given the clinical history and the published medical literature, Hypoglossal Nerve Stimulation (64568 x 1, 0466T x 1) is the best available treatment for this patient at this time. Given the inability to tolerate/use continuous positive airway pressure (CPAP) (the first line treatment), the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient in order to avoid medical complications related to untreated OSA. 

The carrier's denial of coverage for Hypoglossal Nerve Stimulation (64568 x 1, 0466T x 1) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She has a past medical history significant for HTN (hypertension), dyslipidemia and TB (tuberculosis). She was referred to the ER for evaluation of chest pain for two weeks duration. 

The patient was hemodynamically stable. ECG (electrocardiogram) revealed normal sinus rhythm with no ST segment deviation, non-specific T-wave inversion. Troponins were measured and were negative. BNP (brain natriuretic peptide) was 42. Chest X-ray was negative. 

The patient underwent coronary angiography, which revealed no evidence of significant coronary artery disease, and she was discharged home.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a coronary angiogram, which was normal. There was no evidence of CAD (coronary artery disease). There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right ectopic pregnancy.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a woman G5 P4 who was admitted to the hospital after a diagnosis of ectopic pregnancy was made during an admission to the emergency room. A laparoscopic salpingectomy was performed. The procedure was performed without complications and a 400 cubic centimeter (cc) blood loss including hemoperitoneum found prior to salpingectomy. The patient was transferred to the post-anesthesia care unit (PACU) where she recovered without incident. Her vital signs were normal, and she was afebrile. The patient was admitted to the inpatient service.

No, the proposed treatment was not medically necessary. 

The medical records and medical literature were thoroughly reviewed. There are no medical records to confirm that the patient was admitted to an inpatient floor. The medical records indicate that the patient was transferred to the operating room directly from the emergency room, where she was observed and noted to be in no acute distress and hemodynamically stable. Therefore, inpatient admission was not medically necessary prior to the procedure. 

A laparoscopic approach was used to perform the salpingectomy, which required small abdominal incisions. According to the medical records, the patient was afebrile, and her vital signs were normal and stable during the entire postoperative period in the PACU. There are no medical records submitted that indicate the patient's post-PACU stay on an inpatient floor, if there was one. Therefore, according to the medical records, the patient was discharged from the PACU. The post-operative period in the recovery room was uncomplicated and the patient's condition was stable, with stable vital signs. The patient did not have serious co-morbidities to be a complicating factor in her preoperative and postoperative care plans. The patient was likewise stable on discharge from the recovery room. Stable postoperative patients who have undergone uncomplicated procedures such as the above do not require acute inpatient admission. Patient such as that may be reliably observed, by the standard of care, in an ambulatory or intermediate postoperative care unit prior to their eventual discharge.  Therefore, the patient could have been reliably discharged from the recovery room to an intermediate observation unit rather than an acute inpatient room. The treatment did not have to be provided in an acute inpatient setting and was not medically necessary. Withholding the treatment, in whole or in part, cannot reasonably be expected to affect the patient's health adversely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids and menorrhagia 
Treatment: Inpatient hospital stay 

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

The patient was a female with a diagnosis of fibroid uterus and menorrhagia who was referred by her provider to the hospital for evaluation of anemia. The patient reported having low hemoglobin and hematocrit several months prior, and required blood transfusion. The patient reported that she had been feeling tired and short of breath on exertion. The patient's lab studies were significant for hemoglobin of 5.8 and hematocrit of 22.3. The patient received intravenous normal saline bolus. The patient was admitted for further evaluation and management of anemia. The patient received 3 units of packed red blood cells without adverse reactions. The patient was also treated with ferrous sulfate and acetaminophen. The patient's vital signs remained stable. The patient's post-transfusion hemoglobin/hematocrit (H/H) was 9.6 and 32.6, respectively. The patient was medically stabilized and discharged home with instructions to follow up with her primary care doctor and gynecologist in 1 week. 

Based on the review of the medical record, this patient was complaining of fatigue and weakness, in other words, she had symptomatic anemia. This patient also fulfilled the transfusion guidelines for use of blood components for her hemoglobin level was less than 8 g/dL and she was symptomatic. Thus, her blood transfusion was medically necessary. However, this did not warrant inpatient admission. The patient could have been transfused in the Emergency Department (ED) and be monitored for a few hours for adverse reaction. The patient's post-transfusion hemoglobin/hematocrit lab could have been followed up as outpatient within 24 hours of transfusion with her gynecologist. Nothing was done in the hospital that could not have been done as an outpatient. As per MCG clinical guideline for anemia, inpatient admission is indicated for the following reasons: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, and/or syncope. None of these clinical indications applied for this patient's case. The patient could have been transfused in the observation area and discharged after finishing her transfusion. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: inpatient admission

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

This patient is a female who presented to the Emergency Department on with a two day history of abdominal pain located on the right lower quadrant accompanied by nausea and constipation.  There was no history of vomiting with this incidence.  Last menstrual period (LMP) was reported as several weeks prior to this episode.  There was no fever and temperature max through this encounter was noted as 37 degrees centigrade.  Past medical history is noted for hypothyroidism and eczema.  Medications noted as Levothyroxine and Triamcinolone ointment. She reports having had hard stools the day prior.  She rated her pain scale on arrival to the Emergency Department (ED) as 7/10.  Vital Signs in the ED was weight 50kg, blood pressure (BP) 100/65, and respiratory rate (RR) 18.  Complete blood count (CBC), electrolytes, urinalysis (UA), and C- Reactive Protein (CRP) obtained in the ED were normal.

Ultrasound obtained showed "no definite suspicious secondary sonographic signs, the appendix is identified."  So, an MRI was obtained which showed "No evidence of appendicitis, non-specific small volume of ascites (fluid) predominantly within the right hemipelvis, possibly reflective of recently ruptured ovarian cyst".  Fleet enema was given with production of BM, but she still complained of pain after.  Surgery consult note said to "admit for observation" and pain control.  The progress notes state "admit for observation."  The patient had a peripheral intravenous (IV) line that was saline locked as she was allowed oral (PO) clear fluids.  Pain control was handled with oral Tylenol or Motrin as needed (prn) with pain improvement.  No IV pain medication was administered.  She was on a regular diet.  She was discharged the next day with instruction to follow up with her pediatrician.

Based on the documentation on the reviewed records, the inpatient admission cannot be considered medically necessary based on the MCG 23rd Edition guidelines for General Pediatric Admission and Abdominal Pain in a pediatric patient.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Attention deficit disorder 
Treatment: Vyvanse, three capsules (150mg/day) 
The insurer denied the Vyvanse, three capsules (150mg/day).
The denial is upheld. 

The patient is a male. He reports that he was diagnosed with ADD (attention deficit disorder). He states that he tried a number of medications without success, and that he first tried Vyvanse  at a dose of 30 mg twice daily. He found it had limited therapeutic value. 

The patient's dose has been titrated to 50 mg three times daily. The patient reports that this dose is very effective and has "minimal to no side effects." The patient states that at this dosage, he is able to stay focused throughout the day, stay organized, keep on task, finish tasks, exercise impulse control, and have better concentration.

No, the treatment with Vyvanse three capsules (150mg/day) is not medically necessary.

Maximum manufacturer-recommended dose of Vyvanse is 70 mg daily. Safety and efficacy have not been established for higher doses. The patient's insurer limits doses to 50 mg daily but notes that a larger quantity may be approved based on good support for a higher dose in published medical literature or nationally excepted drug references. No such support has been submitted. 

Vyvanse, like all stimulants, has a high potential for dependence and tolerance, and presents significant risks for serious adverse effects at higher doses.  Although the patient asserts that he responds very positively to the current dose, gradual reduction to a more reasonable dosage would not be an unreasonable course of action. 

Drug studies are generally based on an average body weight of 170 lbs. This patient weighs 210 lbs.  Also, since there is significant variability in the metabolism of stimulant metabolism, a dose of two 50mg capsules (100mg daily) would not be outside of the bounds of accepted standard of care for patients such as this. Considering the significant risk profile of excessive dosing, it would be difficult to justify, in terms of safety, the current request of 150 mg daily. Therefore, the request for Vyvanse three capsules (150mg/day) is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post delivery; maternal bonding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female (G8P7017). She was transferred to the hospital on postoperative day two from another facility at which she had undergone a repeat Cesarean section and tubal ligation.  The reason for the transfer was that the baby had to be transferred to the hospital for jaundice and phototherapy. It was believed that it was most appropriate for her to continue her postoperative recovery at the hospital where she could bond with the baby.  At the time of transfer she was afebrile, tolerating PO (by mouth), ambulating and voiding without difficulty. Her postoperative recovery at the hospital was uncomplicated and she was discharged home on postoperative day three.  

The health plan contends that the admission was not medically necessary because the patient had normal vital signs and oxygenation, a well-healing incision, and that the care could have been given at observation level and cites MCG 23rd edition GRG Obstetrics and Gynecology Disease.  The facility contends that the admission was medically necessary due to statutory requirements from the NYS DOH (New York State Department of Health) that mandates the right to stay with a baby after birth, to breast feed, and if re-hospitalized to receive support for breast feeding.  

Yes, the inpatient admission was medically necessary.  

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists establishes standards for perinatal care.  The length of stay allowed for an uncomplicated cesarean section should be 72 hours excluding the day of delivery unless the physician and patient jointly wish to shorten this time.  In addition, a mother and baby should be together during this time to optimize bonding for the dyad, as well as to address feeding issues.  Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute ischemic stroke

Treatment: Inpatient hospital admission 

The insurer is denied coverage for inpatient hospital admission.

The denial is overturned. 

The patient is a male with a past medical history of myocardial infarction and stent, hyperlipidemia, chronic obstructive pulmonary disease, heavy smoking, and non-insulin-dependent diabetes mellitus. The patient presented to the emergency department (ED) with complaints of 6 hours of left hand numbness and tingling. Upon examination, the patient's pupils were equal and reactive to light. The patient's cranial nerves II through XII were grossly intact. The patient's musculoskeletal strength exam was full, 5/5 throughout. The patient's sensation was grossly intact to light touch in all extremities.  There were no cerebellar signs, no dysmetria, and bilateral finger-to-nose was equal and symmetric. The patient's speech was clear. The patient's differential diagnoses included radiculopathy, neuropathy, cerebrovascular accident (CVA), acute coronary syndrome, arrhythmia, anemia, and electrolyte/metabolic derangements. The patient was neurologically intact. The patient was given aspirin full dose total. The patient's computed tomography (CT) scan of the head was negative for acute pathology. The patient was to undergo magnetic resonance imaging (MRI) with higher sensitivity for CVA given his symptoms. The patient underwent a neurology consultation. The patient's MRI of the brain revealed multiple acute/subacute lacunar infarcts in the right occipital lobe as well as the right posterior, frontal, and parietal lobe superiorly. The patient was diagnosed with an acute ischemic stroke. This patient's inpatient admission was medically necessary and fulfilled the InterQual 2019 Acute Adult Stroke criteria for the inpatient level of care. 

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 is overturned.  The medical necessity is substantiated.