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

Diagnosis: Diabetic ketoacidosis. 
Treatment: Inpatient hospital. 
The insurer denied coverage for Inpatient hospital. 
The denial is overturned. 
 
The patient is an adult female with a past medical history of insulin dependent type II diabetes [with prior diabetic ketoacidosis (DKA)], coronary artery disease (CAD), high density lipoproteins (HDL), asthma, thyroid cancer (status post thyroidectomy on Synthroid) presents to emergency room (ER) with nausea and vomiting and tachycardia, and hyperglycemia (blood glucose 739), no abdominal pain or diarrhea, has strong ketone breath odor. Suspected DKA. 

Potential hydrogen (PH) 7.12, Partial pressure of carbon dioxide (PCO2) 20.6, Bicarbonate (HCO3) 6.7, Lactate 3.4, Potassium 4.6, Sodium 151, Phosphorus 8.3, direct Bilirubin 0.7, alkaline phosphatase 168, anion gap (more than) > 33, anion gap with Potassium (K) (more than) > 38, estimated glomerular filtration rate (eGFR): 61.8 2 [Reference Range: >=90.0]. 

Sepsis risk score = 3.52 

Hospitalization for DKA is universally medically necessary(1-9). Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require ICU level care(1),(3),(4),(5) until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care(10),(11).  Most hospitals admit patients with DKA to the ICU (intensive care unit) due to rules regarding level of service with every one hour (q 1h) blood draws and nursing rules. The patient was admitted because she had diabetic ketoacidosis. 

She met the criteria for the diagnosis of DKA. The admission is consistent with generally accepted standards of medical practice and is therefore medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission  is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: obesity
Treatment: stomach surgery/inpatient stay
The insurer denied stomach surgery and an inpatient stay
The health plan's determination is overturned. 

This patient is a woman who is morbidly obese and is seeking treatment for this condition. Per the preauthorization letter, she has a current body mass index of 38.05 associated with comorbidities of asthma and fatty liver disease. She is 60 inches tall and weighs 199 lbs (pounds). She was enrolled in a multidisciplinary bariatric program. She consulted with a registered dietician and received nutritional counseling and education. She has completed a mental health assessment and was cleared for surgery from a psychological standpoint. Abdominal ultrasound showed an enlarged fatty liver. Thyroid stimulating hormone (TSH) is normal.

Surgical Procedure on the Stomach (Surgery for Weight Loss) with Associated Inpatient Hospital Admission is medically necessary for this patient. The Milliman Care Guidelines (MCG) Health 26th ed. Gastric Restrictive Procedure, Sleeve gastrectomy by Laparoscopy state that the goal length of stay is 1 day post-operative. This assumes optimal recovery, decision making, and care. Extended stay beyond the goal length of stay may be needed for staple line leak, conversion to open surgery, complications of the procedure, diet not tolerated, care for comorbidities. These guidelines state that the level of care is from operating room (OR) to Intensive Care Unit (ICU), telemetry, or floor.
In this case the patient has a current body mass index (BMI) of 38 and she has successfully completed a multidisciplinary presurgical bariatric assessment with surgical, nutritional, and mental health components. She has been cleared for surgery from a mental health standpoint and there is no medical contraindication for the proposed bariatric intervention. Her BMI of 38 does qualify her for the proposed bariatric surgery (with or without weight related comorbidities) per the most recent Guidelines for bariatric surgical patient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Deep neck space infection.
Treatment:  Inpatient admission.

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

This is an adult male, who presented with concerns for a deep neck space infection. The patient reported significantly decreased oral intake. Imaging demonstrated concern for an abscess in the prevertebral space; this necessitated an inpatient hospital stay for fluids and intravenous (IV) antibiotics. 

Imaging demonstrated concern for an abscess in the prevertebral space. Impression on Imaging was soft tissue edema and cellulitis in lower neck and pleural effusion. There was severe dysphagia, causing a decrease in oral intake and an inability to take antibiotics / fluids by mouth, due to the deep neck space infection. Further short-term monitoring indicated a failure of symptom improvement. As such, due to the need for continued monitoring, the inpatient treatment would be appropriate and should be approved.

Per Jain, H., Knorr, T. L., & Sinha, V. (2023), "A retropharyngeal abscess is an uncommon but potentially life-threatening diagnosis. This disease is most common in children under the age of five but also occurs in adults. Typically, patients under the age of five have an antecedent upper respiratory tract infection leading to suppurative cervical lymphadenitis and eventually retropharyngeal abscess. In older children and adults, a retropharyngeal abscess can be caused by trauma to the posterior pharynx, which leads to inoculation of the retropharyngeal space and results in abscess formation. Primary infections of the tonsils and of the dentition can also evolve into retropharyngeal abscesses, though more commonly into peritonsillar (Quinsy) or parapharyngeal abscesses, respectively. Direct expansion from spinal discitis or osteomyelitis is a rare cause of a retropharyngeal abscess as well. As a retropharyngeal abscess grows in size, it can lead to upper airway obstruction and asphyxiation. Treatment of retropharyngeal abscess ranges from prolonged courses of intravenous antibiotics to surgical incision and drainage.

All patients presenting with a confirmed diagnosis of retropharyngeal infection require hospital admission, intravenous antibiotics, and otolaryngology consultation. Antibiotic therapy should cover upper respiratory organisms, including anaerobic organisms. Patients presenting airway compromise should have immediate surgical incision and drainage performed to relieve their upper airway obstruction."

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis

Treatment: Inpatient Admission

The insurer denied coverage for: Inpatient Admission

The denial is: Reversed

The patient has a history of idiopathic acute pancreatitis and presented with abdominal and back pain. The patient was admitted to the hospital the previous month with similar complaints. The patient had recently used alcohol and cocaine and was afebrile and hemodynamically stable had abdominal tenderness but no rebound or guarding. A computed tomography (CT) scan was read as severe acute pancreatitis with pancreatic and peripancreatic edema. The lipase was 1035 (normal up to 83). Intravenous (IV) hydration and pain medications were given. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-250 for Pancreatitis. Clinical indications for admission include having acute pancreatitis as indicated by 2 or more of the following: Abdominal pain, serum lipase greater than 3 times the upper limit of normal, and findings on imaging indicative of acute pancreatitis. This patient had all 3 of these criteria. This met MCG guidelines for admission for pancreatitis.

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

Diagnosis: Colitis.
Treatment: Inpatient admission.

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

This is a patient who had a diagnosis of colitis. The patient was treated with medications and fluid by vein. There is no documentation that the patient did not get better after observational care. The requested service was denied based on Milliman Care Guidelines (MCG) 26th Edition using the guideline of Gastroenteritis ORG: M-270. The request is for inpatient hospital admission.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. There was no bowel obstruction, hemodynamic instability, or persistent vomiting. The patient had an infection; yet the patient did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.

Per Rubin, D. T., Traboulsi, C., & Rai, V. (2021), "Patients with ulcerative colitis (UC) can experience periods of recurrent disease activity with a range of symptoms, including abdominal pain, rectal bleeding, urgency, and diarrhea. Although long-term remission will be achieved and maintained in most cases, the course of UC varies from patient to patient. Patients can be defined according to whether they are in remission or have mild, moderate, severe, or fulminant disease, and hospitalization can occur under different circumstances. In these cases, determining the next course of therapy is essential."

Per Huh, G., et al., (2019), "The introduction of biologics since 2000 has improved quality of life of patients and has led to a steady decrease in hospitalization and surgery for inflammatory bowel disease (IBD). A meta-analysis reported that anti-tumor necrosis factor (TNF) biologics reduced the odds of hospitalization for Chron's Disease (CD) and UC by more than half and surgery by 33% to 77%. In UC, a serum C-reactive Protein (CRP) level > 0.5 milligrams (mg)/deciliter (dL) was the only independent risk factor to predict hospitalization. Disease extent was not a risk factor for hospitalization. For UC, hospitalization days in patients were not associated with the extent of disease."

Per Verma, A., Varma, S., Freedberg, D. E., & Axelrad, J. E. (2022), "Over 90% of IBD patients hospitalized with flare with an emergency department (ED) presentation score of 0 did not require salvage therapy, inpatient colectomy, or experience prolonged length of stay (LOS). A simple ED-based score may provide prognosis at a juncture of uncertainty in patient care."    

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Panic Attack

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission 

The denial is upheld 

This the case of a patient that presented to the hospital with tingling of the face, lightheadedness and near syncope.  The patient was driving when symptoms began and they noted tingling over the entire face and began to hyperventilate. The patient noted that they also had blurry vision. Symptoms lasted for one minute and resolved spontaneously.  Past medical history was significant for hypothyroidism. On arrival to the hospital vital signs were stable, with blood pressure (BP) 135/75 and pulse 73. Physical examination revealed no abnormalities and neurologic examination was unrevealing. 12 lead electrocardiogram (EKG) demonstrated normal sinus rhythm with inverted T waves in III and aVF Ventricular Fibrillation without ST segment abnormalities. Serum blood testing demonstrated no significant abnormality. A computed tomography (CT) angiography head did not reveal evidence of stroke or intracranial vascular disease.  The patient was admitted to the telemetry ward with a diagnosis of transient ischemic attack (TIA). Neurology evaluation concluded that the patient had a panic attack rather than a TIA. The patient was discharged the following day with outpatient follow up. 

The health care plan acted reasonably with sound medical judgment and in the best interest of the patient. Acute inpatient admission was not medically necessary. This patient presented to the hospital following a panic attack.  Examination, laboratory testing and a CT of the head revealed no abnormal findings.  Most patients with palpitations can be evaluated in the outpatient setting (Reference 1-2). Average length of stay in patients presenting with stroke was five days in a large national study that included more than four million subjects (Reference 3).   However, this patient did not have a stroke and neurology concluded that the patient had a panic attack rather than a transient ischemic attack. In conclusion, inpatient admission to the hospital was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Heartbeats (supraventricular tachycardia)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female for whom an inpatient hospitalization is under review. The patient presented with palpitations. The heart rate was 210. She was administered adenosine. The heart rate improved to 80. Other vital signs and the oxygen saturation were normal. Electrolytes were normal. The troponin was negative. She was diagnosed with a supraventricular tachycardia. Echocardiography demonstrated normal left ventricular ejection fraction (LVEF) and mild aortic insufficiency. She remained in normal sinus rhythm. Her symptoms resolved. She remained stable and was discharged.

The inpatient admission was not medically necessary.

This patient presented with supraventricular tachycardia (SVT) with successful cardioversion. There was no myocardial infarction (MI), acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, need for prolonged intravenous medication, cerebrovascular accident (CVA), altered mental status, respiratory distress, recent thromboemboli, severe underlying structural heart disease, need for acute anticoagulation, introduction of high-risk antiarrhythmic medication requiring in hospital monitoring, need for ongoing oxygen support, severe electrolyte abnormality, or a recurrent unstable arrhythmia. In the setting of this case, an acute inpatient level hospitalization, compared to a lower level of care, has not been established as standard of care toward improved cardiac outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of palpitations, chest and shoulder pain, and lightheadedness. Per EMS, the patient was found to be in atrial fibrillation with a ventricular rate of approximately 200 beats/minute. Her medical history was remarkable for untreated hypertension and obesity. In the ED, her blood pressure was 163/100 with a heart rate of 159 beats/minute. Her room air oxygen saturation was 97%. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. Chest X-ray showed no acute pathology. The patient was treated with intravenous diltiazem bolus and continuous infusion and with oral diltiazem. She was admitted to the hospital. 

Based on the documentation provided, the inpatient hospital admission was not medically necessary.
This woman presented with acute atrial fibrillation (AF). She was hemodynamically stable, there was no evidence of acute ischemia, she was not in decompensated heart failure and was not at high short-term risk for thromboembolism. For patients presenting with acute AF, the safety of observation level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization."
Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history (PMH) of traumatic aortic dissection who was admitted with complaints of (c/o) chest pain radiating to the back. The patient was recently seen for the same complaint with a negative chest computed tomography angiography (CTA). The vital signs were remarkable for an elevated blood pressure (BP). The physical exam was unremarkable. Lab work was unremarkable, with a negative troponin. Imaging studies included a chest x-ray (CXR) that showed no acute pathology, magnetic resonance imaging (MRI) of the lumbar (L)-spine which showed mild central stenosis and small disc bulging. An electrocardiogram (EKG) showed sinus tachycardia without evidence of acute ischemia. The patient was diagnosed with chest pain and hypertensive urgency, which was considered unlikely to be related to recurrent aortic dissection, and treated with acute coronary syndrome (ACS) rule out (r/o), serial electrocardiogram (EKGs) s, oral hypertensives, and symptomatic treatment. Cardiology evaluated the patient and determined that the chest pain was unlikely due to cardiac or aortic disease. Orthopedics was consulted for back pain and they recommended pain control, physical therapy (PT), steroids, and a Lidoderm patch. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) chest pain radiating to the back without evidence of severely compromised neurological function. The patient received a thorough diagnostic and imaging work-up, which did not demonstrate any acute fractures or dislocations. The patient did not have an an abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess or hematoma, acute spinal fracture, meningitis, osteomyelitis, progressive neurologic deficits, fever, discitis, or tumor. Cardiology evaluated the patient and determined that the chest pain was related to neither cardiac or aortic dissection, while the EKG was without acute ischemia and troponins were negative. Orthopedics evaluated the patient and did not recommend any acute surgical intervention and an MRI showed no cord or cauda equina compression. The patient received intravenous (IV) pain control, steroids, radiologic work-up and PT, all of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: arthritis, diabetes and kidney disease

Treatment: Personal Care Aide (PCA) level 2: 6.5 hours/day, 7 days/week for a total of 45.5 hours/week

The insurer denied coverage for: Personal Care Aide (PCA) level 2: 6.5 hours/day, 7 days/week for a total of 45.5 hours/week

The denial is:  Reversed  

This is an elderly patient with chronic medical problems including arthritis, diabetes and kidney disease. The patient lives with spouse who is supportive and involved in providing some care.   The insurer approved Personal Care Aide (PCA) level 2: 24.5 hours/week. The patient requested  PCA level 2: 6.5 hours/day, 7 days/week for a total of 45.5 hours/week; leading to an external review.

According to the Uniform Assessment System (UAS) report the patient's cognition is described as modified independent. The patient was able to verbalize an emergency plan and was self-directive. The patient requires maximal to extensive assistance for performing much Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires extensive assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Limited assistance is needed for personal hygiene, upper body dressing and bed mobility. The patient is reportedly independent with eating. The patient is frequently incontinent of bladder and continent of bowel. There was one reported fall over the prior 30 days.  

The patient's treating physician described the patient's clinical condition and need for additional home care services was reviewed. The patient's functional ability has significantly declined compared to the UAS report. The patient's clinical condition and functional deficits have declined to a level and unpredictable as to require the requested  Personal Care Aide (PCA) Level 2: 6.5 hours per day- 7 days per week - for a total of 45.5 hours per week. Based on the documents reviewed, the patient's functional needs can be more appropriately provided and maintained by increasing PCA services 6.5 hours/day, 7 days/week, total 45.5 hours/week. The patient also has the option of restructuring and flexibly using the 45.5 PCA hours weekly to better maintain and meet the patient's functional needs.  

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, Personal Care Aide (PCA) Level 2: 6.5 hours per day- 7 days per week- for a total of 45.5 hours per week is medically necessary.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) level 2: 6.5 hours per day - 7 days per week - for a total of 45.5 hours per week is substantiated.