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

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

The patient presented to the emergency department with concerns for altered mental status and hypoglycemia. Emergency Medical Services (EMS) was called and observed recurrent hypoglycemia and confusion despite dextrose administration. His pertinent history included diabetes mellitus, chronic kidney disease, hypertension, peripheral vascular disease, and congestive heart failure. The initial vital signs revealed the patient to be afebrile and hemodynamically stable. The initial examination documented the patient as alert and at baseline mental status. A computed tomography (CT) scan of the head was unremarkable. The patient was admitted to the hospital with an impression of altered mental status likely due to hypoglycemia in the setting of insulin dependent diabetes mellitus as well as acute kidney injury superimposed on chronic kidney disease. The treatment plan included dextrose isotonic infusion and withholding insulin. There were no new issues and the patient had no complaints. The blood glucose returned at 134 and 145 milligrams per deciliter (mg/dL). The patient's mentation remained at baseline. The dextrose was removed from the intravenous fluids. There was no recurrent hypoglycemia. The serum creatinine decreased. There was no significant treatment change. There were no new issues. There was no recurrence of hypoglycemia or confusion. The serum creatinine continued to trend downward. The patient was discharged to home.
At issue is the medical necessity of an inpatient stay.

An acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient had a history of diabetes mellitus and chronic kidney disease. Upon arrival to the emergency department, his mental status had returned to baseline and the hypoglycemia had resolved. The treatment plan included a dextrose infusion and continued monitoring of blood glucose. The hypoglycemia had resolved and mentation remained at baseline. No other issues or complications requiring an acute inpatient level of care were documented.
Clinical indications for admission to inpatient care were not met. The patient did not have severe or persistent altered mental status, neurologic findings that are recurrent of persist despite observation care treatment, other significant clinical signs or symptoms of hypoglycemia that do not resolve with lower level of care treatment, persistent or recurrent hypoglycemia despite observation care treatment (eg, hypoglycemia due to a long-acting agent, patient unable to maintain glucose levels via oral intake alone), prolonged monitoring for recurrent hypoglycemia (ie, beyond observation care) deemed necessary (eg, use of very long-acting hypoglycemic agent, ability of patient to maintain euglycemia orally uncertain).[2]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, Family History of Coronary Artery Disease.
Treatment: CT heart without contrast.
The insurer denied CT heart without contrast.
The determination is overturned.

The patient has a history of hypertension, proteinuria and breast cancer. Her family history is remarkable for coronary artery disease and coronary artery bypass graft surgery in her mother. Her brother had coronary bypass graft surgery. Her low-density lipoprotein (LDL) cholesterol level was 139 milligrams per deciliter (mg/dl). Based on these values, her estimated 10-year risk of an atherosclerotic event per the Pooled Cohort Equation was 4.2%. She was treated with Rosuvastatin, which was discontinued due to side effects. A computed tomography (CT) scan for coronary artery calcium scoring was performed; her coronary calcium score was 0 and statin therapy was deferred. At issue is the medical necessity of the CT scan of the heart without contrast material.

Based on the documentation provided, a CT scan for coronary artery calcium scoring was medically necessary in this instance.
This patient has cardiac risk factors of hypertension, hyperlipidemia and a strong family history of premature atherosclerotic cardiovascular disease (ASCVD). Based solely on her 10-year atherosclerotic cardiovascular disease (ASCVD) risk score, she is at low risk for an ASCVD event. However, this scoring system is imperfect and does not take the family history into account. Accurate risk stratification is important in guiding clinical decision-making regarding lipid-lowering therapy in asymptomatic patients without diagnosed ASCVD, particularly in those who have been intolerant to statins. A coronary calcium score of 0 identifies a population with a low risk of mortality over a period of 15 years, regardless of their Framingham or Pooled Cohort Equation risk scores. In this situation, lipid lowering therapy is generally considered to be unnecessary. Conversely, the presence of significant coronary artery calcium substantially changes risk estimations. In this situation, statin or other lipid-lowering therapy may be indicated, regardless of the Framingham or Pooled Cohort Equation risk scores. For patients with a family history of premature ASCVD, the addition of a coronary artery calcium score to other traditional risk factors significantly refines risk prediction, including the ability to predict ASCVD mortality. In a study of 8549 asymptomatic individuals, a history of premature ASCVD in both a parent and a sibling was highly predictive of the presence of coronary artery calcium (Nasir et al) and, thus, of atherosclerotic plaque. The National Lipid Association scientific statement on coronary artery calcium scoring to guide preventive strategies for ASCVD risk reduction supports the use of this modality in low-risk adults, such as this patient, with a strong family history of premature coronary artery disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis, Left Elbow
Treatment: Hospital admission
The insurer denied coverage for hospital admission.
The denial is overturned.

The patient is a male with past medical history significant for diabetes mellitus and attention deficit hyperactivity disorder (ADHD) who presented to the emergency department (ED) with complaints of worsening left elbow pain following an insect bite. 
Vitals on presentation included: temperature 97.9 Fahrenheit, blood pressure 152/85, pulse 103, respiratory rate 18, oxygen (O2) saturation 100% (percent) on room air. Laboratory values were notable for the following: white blood cell count (WBC) 12.8, hemoglobin 14.4, hematocrit 42, creatinine 1.1, glucose 447. 

The patient was admitted for cellulitis of the left elbow. He was started empirically on antibiotics (vancomycin and ceftriaxone) and underwent an incision and drainage procedure. Infectious Diseases consulted. Compute tomography (CT) scan of the arm showed diffuse cellulitis and fasciitis. Wound cultures grew methicillin-sensitive staphylococcus aureus (MSSA). The patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics as an outpatient.

According to documentation, this patient was admitted with left lower extremity cellulitis following an insect bite. He was afebrile, but hypertensive (152/85), and tachycardic (103); laboratory results showed an elevated WBC (12.8) and poorly controlled diabetes (glucose 447, hemoglobin A1c [glycated hemoglobin]> (greater than) 10). CT scan showed diffuse cellulitis/fasciitis. Based on the above findings, this patient required hospital admission for intravenous antibiotics and surgical intervention (incision and drainage).  

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

The insurers denial of coverage for hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Break in bones, left arm (ulna) and right shin bone (tibial plateau) 
Treatment: Inpatient hospital stay.
The insurer has denied the hospital stay.
The determination is upheld.

The patient is a female with end-stage renal disease. She is on chronic hemodialysis and has diabetes and heart disease. The patient presented to the emergency department after suffering a mechanical fall and complaining of right knee pain. The assessment in the emergency department (ED) revealed a right tibial fracture and a left ulnar fracture. Orthopedic surgery assessed the patient and determined she had no surgical intervention needs. Attempts at ambulation were unsuccessful in the emergency department. Physical therapy evaluated the patient and recommended short-term rehab placement. The medical team was asked to admit the patient to the hospital until placement could be provided.

The patient remained in the hospital throughout the following day, with the attending note stating the patient was discharged and was planning to be transitioned to a short-term rehab facility. The process of placing the patient in a rehab setting continued through the day of discharge from the hospital.

Inpatient hospitalization is not warranted in this case. The patient's vital signs appeared stable on admission. The cardiopulmonary exam was fairly unremarkable. Her labs appeared stable and consistent with the hemodialysis patient. The patient was scheduled for a dialysis session on the day of admission for a routine schedule. Case management was consulted for placement pending authorization. The patient was medically cleared for discharge on the day of admission.

Based on the provided documentation, the patient did not require inpatient hospitalization, as indicated by the orthopedic consultant and the medical team. This was a custodial admission and the patient was awaiting placement at the rehab facility. There were no inpatient procedures, or medical necessity for an inpatient level of care to warrant an inpatient admission. The patient suffered a fracture secondary to a mechanical fall that did not require surgical intervention. The medical team clearly documents the reason for the admission is to await placement until case management can make the necessary arrangements. There is no evidence of secondary complications from the patient's fall, such as systemic illness, bleeding, need for emergent surgery, head trauma, or mental status change. Orthopedic surgery recommended outpatient follow-up. The patient remained in the hospital due to a delay in procuring an appropriate short-term rehab facility. This, by definition, is custodial care and does not qualify for inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fatigue, malaise, myalgia. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is an adult male who presented to the emergency room with complaints of generalized fatigue, malaise, myalgia, subjective fever, nausea, decreased oral intake and occasional gradual onset tension type headaches. His past medical history included a body mass index 37. 

Upon emergency department evaluation, the patient was noted with dehydration, fever, fatigue and nausea. The patient complained of pain eight out of ten (8/10) in severity. The patient was noted with a blood pressure of 133/88, heart rate of 110 to 115 beats per minute and a temperature of 101.2 Fahrenheit. The patient was treated with intravenous (IV) Maxipime, intravenous Pepcid, intravenous Zofran, intravenous Vancomycin and intravenous fluids were administered.  A computed tomography scan of the abdomen/pelvis was completed and showed hepatosplenomegaly, diffuse hepatic steatosis.  A urinalysis was completed and showed ketones large, bilirubin and urobilinogen. Laboratory tests were done and revealed white blood cell count of ten, platelets of 149, potassium of 3.4, bilirubin total of 2.8/3.9, aspartate aminotransferase (AST) of 307/425, alanine aminotransferase (ALT) of 458/585, sodium of 133, and procalcitonin of 0.88. 

The patient was admitted with a diagnosis of dehydration. The patient was treated with intravenous Ceftriaxone and intravenous fluids were administered. The patient was noted with recurrent fevers overnight of 101.2F. The patient underwent blood cultures times two (x2). 

The proposed treatment was medically necessary. 

The patient was admitted on the medical/surgical unit with a diagnosis of dehydration. The patient was treated with intravenous Ceftriaxone and intravenous fluids were administered. This patient presented with complaints of fever, headache, nausea, fatigue and decreased oral intake. The patient also had fever and noticeably elevated liver function tests. Admission to the hospital was medically appropriate to monitor the patient in view of the above problems. The patient had fever and elevated liver function tests and dehydration and admission was medically appropriate to ensure that fever was improving/stabilized and to ensure that the patient did not clinically deteriorate in view of further elevation of liver function tests. The patient received treatment with antibiotics for possible sepsis. Admission to the hospital was appropriate to allow for further investigations and work up regarding sepsis and elevated liver function tests. Such monitoring / evaluation would not optimally be possible in an outpatient setting or observation setting and therefore the admission to the hospital was medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left Knee Pain.

Treatment:  Magnetic Resonance Imaging (MRI) of the knee, code 73721.

The insurer denied coverage for magnetic resonance imaging (MRI) of the knee, code 73721.  The denial is upheld.

This a patient with intermittent left knee pain. She had an X-ray showing mild degenerative disease with no acute pathology. A magnetic resonance imaging (MRI) was performed which showed 2 ganglion cysts. Plan denying reimbursement for the MRI the basis of no history of a 6-week trial of conservative therapy prior to the imaging study.

The patient has a history of intermittent left knee pain. She had an X-ray showing mild degenerative disease with no acute pathology. The patient has not had the required 6-week trial of conservative management over a 3-month period prior to the performance of the MRI exam. 

According to Expert Panel on Musculoskeletal Imaging: Fox, M. G., et al. (2018), "Chronic knee pain is a condition that is frequently encountered. Imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. The ACR (American College of Radiology) Appropriateness Criteria for Chronic Knee Pain provides clinicians with the best practices for ordering imaging examinations. The following narrative and accompanying tables should serve as useful guides to any clinician. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (Rand/UCLA [University of California at Lost Angeles] Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment."

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

The medical necessity for magnetic resonance imaging (MRI) of the knee, code 73721 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression. 
Treatment: Transcranial Magnetic Stimulation (TMS). 
 
The insurer denied transcranial magnetic stimulation. 
The health plan's determination is upheld. 

The patient has a diagnosis of persistent mood disorder and depersonalization-derealization syndrome. The patient has a history of worsening and persistent symptoms of depression despite past treatments with antidepressant and anxiolytic medications combined with psychotherapy. The patient's symptoms have persisted with deterioration in his functioning which include a medical leave of absence from college. The patient was subsequently referred for consideration of repetitive transcranial magnetic stimulation (RTMS) therapy for thirty-six treatment sessions with tapering over a three-week time frame per protocol. The referral also includes the use of functional magnetic resonance imaging (FMRI) which is a guided transcranial magnetic stimulation (TMS) with brain mapping. The patient did not have severe symptoms such as psychosis, cognitive impairment, perceptual disturbance or suicidal ideation. The patient is noted to have a loss of reality with chronic dissociation, as well as a persistent mood disorder. The patient has no reports of substance use disorder or other mental disorders. The patient has reportedly not been provided treatment with electro-convulsive therapy (ECT) and documentation does not note whether cognitive behavioral therapy (CBT) or other evidence-based psychotherapy is ongoing or has been provided by a skilled and certified therapist. Medication trials included the following: Buspar 10 milligrams (mg), Wellbutrin 150 mg, Prozac 20 mg, Zoloft 25 mg, Lamictal 25 mg and Seroquel 25 mg with the latter prescribed for insomnia and anxiety. 

The health plan denied authorization for coverage of TMS on the basis of coverage exclusion and InterQual Criteria and indicated that the requested treatment is considered as not medically necessary because the patient's diagnosis does not warrant treatment with TMS. There is no standardized assessment for depression.
At issue is the medical necessity for the requested health service/treatment of transcranial magnetic stimulation (TMS). 

The requested health service/treatment of transcranial magnetic stimulation (TMS), 36 units is not medically necessary for this patient. 

Standard of care approaches for the treatment or mood disorder include combination therapy or an established augmentation therapy, as well as specific forms of psychotherapy that would establish that a patient's treatment is refractory. This patient's diagnosis of a treatment resistant depression and the severity of the depressive disorder is not well established. There is no standardized assessment for depression. Medical necessity is not met. This answer is consistent with practice guidelines referenced below, and the scientific literature pertaining to TMS therapy for major depressive disorder.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient has a history of asthma, chronic bronchiectasis and severe bronchiectasis. The patient presented to the emergency room (ER) with complaint of shortness of breath (SOB), wheezing and cough which was productive of white sputum. The patient had been admitted to the hospital recently for pneumonia and was discharged on oral Levaquin.  Vital signs at presentation temperature 98.2 degrees Fahrenheit, blood pressure 118/71 mm Hg (millimeters of mercury), heart rate 78, respiratory rate 18, and oxygen (O2) saturations 94% (percent) on room air. Lung exam revealed bilateral wheezing.  White blood cells (WBC) were 6.9, electrolytes within normal limits (WNL). Chest x-ray revealed fibrotic changes in the right lung and left upper lobe. Computed tomography (CT) chest revealed calcified mediastinal lymph nodes and scarring. No acute changes.  The patient was treated with intravenous (IV) steroids, bronchodilators via nebulizer, and IV Cefepime.  The patient improved with treatment in ER and the plan was to discharge her home with follow up. However, she felt short of breath once oxygen was removed. Prior to that oxygen on room air was recorded as 90%. The patient was placed on 2-liter nasal cannula (NC). The patient was admitted for asthma exacerbation and exacerbation of bronchitis and bronchiectasis. 

This patient continued on treatment with steroids, bronchodilators and IV antibiotics.
The patient had difficulty mobilizing her pulmonary secretions; chest physical therapy and flutter valve was recommended.  As per history and physical (H&P) the patient was in no acute distress (NAD), was not using accessory muscles of respiration, and was able to speak in full sentences. The patient was afebrile and hemodynamically stable WBC was normal. Chest x-ray and computed tomography (CT) showed no acute changes. The patient remained stable after admission and was discharged a few days later on oral antibiotics and steroids.  This patient could have been placed in observation status which could have been for up to 48 hours. The patient could have been treated initially with IV steroids and antibiotics if necessary and then switched to oral medication. The patient could have had chest physical therapy, nebulized saline, and vest or flutter device to facilitate expectoration of mucus. 

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 admission services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eating disorder, substance abuse disorder, severe underweight status. 
Treatment: Air and ground ambulance transportation. 

The insurer denied the air and ground ambulance transportation.  The health plan's determination is upheld. 

The patient is a female who is diagnosed with anorexia nervosa, binge purge subtype (ANBP), of more than five years duration. She overdosed intentionally, and was emergently treated at an outside hospital, from where she was transferred to an alternate hospital and admitted. She was too ill to be treated there, she had a body mass index (BMI) of 14.7. An air ambulance was arranged to transport her to an inpatient center for eating disorders for treatment. Her vital signs were stable and in a reasonable range during her flight. 

The requested health service of air and ground transportation from the hospital to a center for eating disorders was not medically necessary for this patient. There were other internationally recognized centers with inpatient and intensive care availability that were much closer. 

These facilities are respectfully 47 and 250 miles from the hospital the patient was transported from. Transport could be safely arranged by ground ambulance.  

To review, the recent literature on the epidemiology of anorexia nervosa and bulimia nervosa in terms of incidence, prevalence and mortality, both eating disorders may carry a five or more times increased mortality risk. The patient was not in mortal peril. The medical complications above could have been adequately treated at a center closer to the transferring hospital. Additionally, the co-morbidities this patient suffered from could be adequately treated at a facility that was closer to the transferring hospital.