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

Diagnosis: Chest pain
Issue under review: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), dyslipidemia, diabetes mellitus, type 2, CAD (coronary artery disease), status post PCI (percutaneous coronary intervention), PAD (peripheral artery disease), last cath three weeks prior to admission, who presented for evaluation of sharp sub-xyphoid chest pain, non-exertional, with no radiation, piercing to the back. 

The patient was hemodynamically stable. ECG revealed no acute ischemic changes. Cardiac troponins were negative. CTA of the chest was obtained in the ED to rule out aortic dissection and was negative. The patient was admitted to telemetry to rule out ACS (acute coronary syndrome). He was seen in consultation by cardiology. His pain was determined to be atypical, most consistent with muscular-skeletal chest pain and no inpatient ischemic work-up was planned. 

The patient was discharged home with a plan for outpatient follow-up.

No, the inpatient admission is 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. No ischemic work-up was planned in the setting of recent cardiac catheterization. Medical therapy for CAD and HTN was continued. 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 and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces and monthly visits

The insurer is denied coverage for the braces (D8080) and monthly visits (D8670). 

The denial is upheld. 

The patient was a male child. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the HLD index attaining 11 total points to support orthodontic care.  

It is evident that the patient exhibited a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labio-Lingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 11 points to justify for this patient's orthodontic care.  This reviewer concurs with the index completed by this patient's orthodontist attaining a total of 11 points on the HLD index (1 points overjet, 1 points overbite, 5 points anterior crowding, 4 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care.  Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Since this patient's HLD index total score was 11, which was below the threshold of 26 points to justify for orthodontic care, the braces and the monthly visits associated with braces are not medically necessary for this patient.

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

The carrier's denial of coverage for the braces (D8080) and monthly visits (D8670) should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Otitis media 

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is reversed. 

The patient was then a female child who was born at full term but required hospitalization in the Neonatal Intensive Care Unit (NICU) for several weeks because of feeding difficulties and respiratory complications. The patient was sick for days with fever, nasal congestion and a cough. The patient was seen in the Emergency Room (ER) on the day prior to admission and was diagnosed with an otitis media and prescribed Amoxil. The parents had not picked up the prescription and when the child's fever persisted the parents called the medics to bring her to the ER for a second visit. 

In the ER, the patient was noted to have a fever of 103.7 degrees. On physical exam, the patient appeared sleepy, irritable and feeding poorly; there were coarse breath sounds audible in the posterior lung field. The patient received intravenous (IV) fluids for possible dehydration, and ceftriaxone and azithromycin to treat the pneumonia. The patient had a normal complete blood count (CBC) and urinalysis. The patient's chest x-ray indicated the presence of a small infiltrate in the left lower lobe. Since the patient's parents had not obtained the previous antibiotic prescribed when she was seen the day prior to this ED visit, there was concern that the parents would be unable to adhere to medical recommendation to administer antibiotics at home and the decision was made to admit the patient to the hospital for IV antibiotics and continued IV fluids. 

Based on the review of the literature, the patient was treated appropriately in the Emergency Room (ER) for left lower lobe pneumonia and intravenous (IV) fluids because of poor oral intake. The decision to admit the patient was based on the presence of pneumonia and the concern that the patient's parents had not begun oral antibiotics prescribed previously during a visit to the ER the day prior to this admission. If the patient's parents are not felt to be capable of administering the antibiotic at home, it is appropriate and the standard of care to admit the patient to the hospital to ensure that the pneumonia is treated appropriately. Therefore, inpatient admission was medically necessary to treat this patient's medical condition. 

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 should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting
Treatment: Inpatient Admission
The insurer denied the Inpatient Admission.
The denial is overturned. 

The patient is a female child with medical history significant for reactive airways disease presented to her pediatrician with ongoing vomiting and was seen in the ED.  She was given Zofran and discharged. She continued to have vomiting multiple times daily. On the day of admission, she was again seen in the office. She had not had a wet diaper since the day prior and vomited immediately upon challenge. The patient was directly admitted to the pediatric floor for continued management of gastritis with dehydration. She was afebrile with no diarrhea. Vital signs included temperature 98, heart rate 130, respiratory rate 27, and blood pressure 100/70. Examination was significant for dry lips, crying without tears, coughing with post-tussive gagging, mild congestion, brisk capillary refill, tachycardia, non-tender abdomen with positive bowel sounds, and non-focal neurologic exam. She was given an additional diagnosis of acute upper respiratory infection.

This young child was admitted after a prolonged course of vomiting, having been to the pediatrician's office and ED multiple times, treated with Zofran with transient improvement. By the time of admission, she was unable to tolerate food or fluids, with significant decrease in urine output, moderately dehydrated on physical exam. She failed outpatient management and ED management, requiring acute inpatient admission for evaluation and hydration. She could not have been safely managed at a lower level of care. The entirety of the hospital stay was medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Painful And Frequent Urination With Back
Pain, Body Aches And Headache
Issue under review: Inpatient admission 
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female whose inpatient admission is under review. The patient presented with two days of fever, dysuria, urgency, frequency, back pain, and headache. She also noted vomiting and dry cough for two weeks.

In the ER, the patient's vitals were as follows: T (temperature) - 103, P (pulse) - 146, BP (blood pressure) - 91/48. The patient's general examination was normal. The CVS (cardiovascular system) examination revealed the patient to be tachycardic, regular. Examination of the patient's chest and abdomen were normal.

The patient's UA (urinalysis) revealed 26-50 WBC (white blood cells), 5-10 RBC (red blood cells), bacteria TNTC (too numerous to count), squ epi (squamous epithelial) few. Urine culture revealed E. coli (ESBL [extended spectrum beta-lactamase]). Blood culture was negative.

In the ER, the patient was thought to have sepsis and pyelonephritis and was treated with IV ceftriaxone, and she was admitted. She improved over the next two days. Urine culture grew ESBL E. coli, and the patient was discharged on PO (oral) ciprofloxacin.

Yes, the Inpatient admission was medically necessary.

Outpatient treatment for pyelonephritis in women is given for uncomplicated cases (1). In this patient, the pyelonephritis was complicated because of sepsis (tachycardia and hypotension). Standard of care would also require admitting such a patient and treating with IV antibiotics.  

Thus, this admission was warranted, supported by standard of care and IDSA guidelines. Failure to admit such as a patient can lead to loss of function, septic shock, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/Pancreatitis
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. The reviewer has upheld the health plan 
determination. 

The patient had minimal criteria for pancreatitis, and this was likely the correct diagnosis. Patient had a > 3 fold elevation in lipase with pain consistent with pancreatitis by Atlanta criteria.[1] The patient had no evidence of systemic inflammatory response syndrome (SIRS) and had a low simplified acute physiology (SAP) score indicating mild pancreatitis.[2] The patient's CT with intravenous (IV) contrast revealed a normal appearing pancreas indicating this is a mild case.[3] . The patient was essentially symptom free the following day and was able to begin an advancement of diet. The patient could have been safely monitored in a lower level of care setting. No additional diagnostic testing was necessary and there is no specific therapy except avoidance of precipitating factor which in this case was ethyl alcohol (ETOH).[3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/abdominal pain.
Treatment: Inpatient stay.
The insurer denied the Inpatient Stay.
The health plan denial is upheld in whole. 

The inpatient admission was not medically necessary at the acute inpatient level of care. Even though the patient complained of persistent nausea and vomiting, there were no clear signs of dehydration, acute kidney injury, or severe electrolyte abnormalities that can occur in cases of severe dehydration. Patient had epigastric abdominal pain radiating to the back. The severity of the patient's symptoms was disproportionate to the findings on the physical exam, in the laboratory studies, and on diagnostic tests. The patient had no signs of acute pancreatitis based on the CT scan of the abdomen, and a normal lipase level. In general, the symptoms resolved relatively quickly and the patient was able to tolerate a diet. There were no serious medical conditions diagnosed during the hospital stay that would justify admission at the acute inpatient level of care. During the entire admission, the patient remained afebrile and hemodynamically stable. Patient had no signs of severe dehydration or severe electrolyte abnormalities. The patient had no unstable vital signs, persistent vomiting, or severe pain requiring continuous administration of pain medications. There were no signs of bowel obstruction or ileus or inability to tolerate fluids.

Taking into consideration these facts, I do not see a compelling clinical reason why the member could not have safely and appropriately received evaluation and treatment at this facility at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. Admission at a lower level of care to ensure adequate pain control, hemodynamic stability, and stable oral intake was reasonable.
Appeal type: Medical necessity
Decision: Overturned

Cardiac.
Inpatient Hospital.

Diagnosis: peripheral artery disease.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female with a history of hypertension, hyperlipidemia, diabetes mellitus, idiopathic pulmonary fibrosis, previous stroke, paroxysmal atrial fibrillation, and end stage renal disease requiring thrice weekly hemodialysis who presented to the hospital for peripheral angiogram and percutaneous peripheral intervention/revascularization. 

The Inpatient Hospital Admission is medically necessary for this patient. This patient underwent peripheral angiogram, peripheral artery angioplasty, and directional atherectomy to treat her symptoms of bilateral lower extremity pain with ambulation and rest pain. These are considered standard techniques to treat a patient with symptomatic and significant peripheral arterial stenosis.
Due to the patient's severity of peripheral arterial disease as evidenced by non-invasive vascular ultrasound and peripheral angiogram with several stenoses of > 50% severity, reported symptoms of worsening bilateral lower extremity rest pain suggestive of critical limb ischemia, her multiple co-morbid clinical conditions that are considered risk factors for readmission after peripheral revascularization procedures such as diabetes mellitus, hypertension, chronic pulmonary disease, and end stage renal disease requiring hemodialysis as well as technical considerations associated with the procedure such as use of atherectomy to treat the peripheral artery stenosis and single vessel run-off, the inpatient stay was medically necessary.
This patient had multiple peripheral stenosis on non-invasive vascular ultrasound and on peripheral angiography that were > 50% stenosis severity. This patient had rest pain documented on the outpatient vascular surgeon's note. Per the Conte, et al., article from 2019, the patient's symptoms suggest critical limb ischemia. This would be another reason supporting the inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient who was intoxicated, but otherwise healthy when she presented as the victim of an assault. She reported facial pain at the time of presentation. Her Glasgow Coma Score was 15. Heart rate was 80. There was severe facial swelling, ecchymosis and abrasions to the face. Her hematocrit was 37.3. Imaging showed nasal and left inferior and medial orbital wall fractures.
The patient was admitted to the hospital. The next day the left periorbital swelling was worse. Vital signs were normal. She underwent open reduction internal fixation (ORIF) of the fractures the following day. She was treated with perioperative intravenous (IV) fluid, antibiotics and analgesia. In the course of this hospitalization, the trauma service, ophthalmology and oculoplastic services were involved. She was discharged from the hospital with instructions for short term follow up.
At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary.
This patient presented to the ED following an assault. The evaluation and clinical work up identified nasal and left inferior and medial orbital wall fractures. The patient was stable at the time of presentation with normal vital signs. She did require surgical intervention for the facial fractures. However, the care and treatment provided could have safely been rendered at a lower level of care than inpatient, which would allow for the provision of IV fluid, pain medication, surgical therapy, and overnight monitoring. The records support that this patient had an uncomplicated period of observation. She remained hemodynamically stable without aberration of vital signs. There was no hemodynamic instability and the patient was able to tolerate a liquid diet. There was no documentation of severe pain requiring continuous or frequent (every 2-4 hours) parenteral analgesics. Per the Milliman Care Guidelines (MCG): Multiple Trauma 23rd edition, inpatient admission is indicated when a patient with significant multiple trauma requires inpatient care for 1 or more of the following: major surgical and postprocedural care, nonoperative care of significant injuries or other general admission criteria. In this case there were not such requirements for this patient and her care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male post WPW (Wolf-Parkinson White) ablation, who presented with left sided chest pain followed by syncope. The patient was brushing his teeth in the bathroom when he developed severe, pressure like left sided chest pain and left shoulder pain. He sat down and passed out, and his wife found him on the floor. The chest pain was different. The chest pain was worse when he moved his arm.

The Inpatient Hospital Stay is not medically necessary for this patient. The patient presented with syncope and chest pain. He was admitted for evaluation of these conditions. His evaluation and management did not meet inpatient criteria. His condition was stable, without hemodynamic compromise. The patient did not have an acute myocardial infarction (MI) or significant arrhythmia. His syncope was felt to be due to vasovagal episode. The patient had previous history of WPW, but it was not demonstrated during this admission. The patient had previously diagnosed diverticulum of Kommerell, but it felt to be not a cause of syncope or chest pain. The patient was discharged after several studies, such as stress nuclear perfusion test, echocardiogram and CTA.
The patient's condition and level of care did not meet inpatient admission criteria. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary
Nursing Services (including Private Duty Nursing)

Diagnosis: urinary incontinence, benign prostatic hyperplasia 
Treatment: Consumer Directed Personal Assistance Services: 12 Hours per Day/7 Days per Week 
The insurer denied the Consumer Directed Personal Assistance Services: 12 Hours per Day/7 Days per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of severe vascular dementia with behavioral disturbance, urinary incontinence, benign prostatic hyperplasia (BPH), intermittent bowel incontinence, anxiety, depression, degenerative joint disease of the lumbar spine, degenerative joint disease of the knees, osteoporosis, coronary artery disease (CAD), congestive heart failure (CHF), atrial fibrillation on anticoagulation, hypertension, hypothyroidism, pancreatic insufficiency, diplopia, neuropathy and frequent falls.

Consumer Directed Personal Assistance Services: 12 Hours per Day/7 Days per Week are medically necessary. The patient has documented worsening of severe vascular dementia as well as degenerative joint disease of the spine and the knees necessitating prompting and supervision for activities of daily living (ADL) and Instrumental activities of daily living (IADL) and increased assistance with dressing, walking, locomotion, transfer toilet, toilet use, incontinence cares and bed mobility. The assessment tool performed late 2019 underestimated the patient's needs as supported by the medical necessity letter from the patient's PCP and neurologic providers. The patient has unscheduled needs and requires assistance and prompting for these ADL's. The patient would require ambulatory assistance to get to the bathroom and increased assistance with toileting and incontinence care. The patient has CHF with the need for diuretic therapy which further increases unscheduled needs. The patient is on a blood thinner to treat atrial fibrillation which puts him at increased risk for bleeding with recurrent falls. An increase in PCA service hours is not solely for safety and supervision as the patient requires prompting and supervision for completion of ADL's and IADL's.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:Orthopedic/Musculoskeletal
Treatment: Prosthetics
The insurer denied: prosthetic leg replacement surgery (replacement hip socket and hip joint)
The denial is: Overturned, in whole.

The patient is a male who required a left hip disarticulation following a go kart accident several years ago. He has had his current prosthesis for four years. The residual limb size and shape has changed. Therefore, the patient needs a replacement socket and hip joint. The subject under review is the medical necessity for the replacement socket and hip joint is medically necessary for this patient.

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

The requested socket and hip joint replacement on the patient's existing hip disarticulation prosthetic is medically necessary and in the best interest of the patient.
This is not a surgery but instead a prosthetic component replacement. The patient is a male with a past surgical history significant for left hip disarticulation. He has had his current prosthesis for four years. Documentation notes that his residual limb size and shape has changed. Without this requested socket he will be at increased risk of skin breakdown and infection. In addition, a replacement hip joint is medically necessary as the patient's current hip joint was bent due to a fall.