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

Diagnosis: Recurrent cancer treated with chemotherapy.
Treatment: Inpatient admission.

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

The patient is a female with a history of an International Federation of Gynecology and Obstetrics (FIGO) Stage IIIC cervical cancer treated in the past with chemoradiation therapy and now with recurrent cancer. The patient has been treated with carboplatin, taxol and avastin and received cycle #1. She presented with complaints of dysuria, diarrhea and nausea. She had a non-focal exam, stable vital signs, and labs and was admitted for further evaluation.

No, the proposed inpatient admission was not medically necessary.

The proposed admission was not medically necessary. The patient had stable vital signs, a non focal exam, normal blood tests and was able to ambulate, void and take oral medication and oral diet so that she did not have any conditions that required inpatient level of care. Admission for her diarrhea, dysuria and nausea is not supported by peer-reviewed literature, it is not standard of care, and it is not supported by professional organizations.

The patient had stable vital signs, a non focal exam, normal blood tests and was able to ambulate, void and take oral medication and oral diet so that she did not have any conditions that required inpatient level of care. Admission for her diarrhea, dysuria and nausea is not supported by peer-reviewed literature, it is not standard of care, and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain.
Treatment: Inpatient admission.

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

This male patient has a history of asthma and polysubstance abuse who presented to the Emergency Department (ED) with complaints of chest pain for 2 weeks, abdominal pain, tongue lesions, nausea, vomiting and diarrhea. The patient reported chest pain in the mid-sternal region after ingesting crack and drinking alcohol the night prior. He was hemodynamically stable. The electrocardiogram (EKG) showed sinus rhythm at 66 beats per minute with trigeminy. The lab work was notable for the following:  leukopenia 3.04, lactate 2.3, hyponatremic 131, hypochloremic 93, elevated blood urea nitrogen (BUN) of 28, creatinine 1.1, troponin negative x 1. The chest X-ray did not have evidence of consolidation or infiltrates, and no cardiomegaly. He was treated with intravenous (IV) fluids, and was given vancomycin and Tylenol in the ED. His temperature was significant with a fever of 101.8 degrees Fahrenheit. He was admitted to the Telemetry Unit for chest pain in the setting of substance abuse with concerns for possible endocarditis and sepsis. The patient's follow-up troponin levels were negative x 2, and a myocardial infarction was excluded. He was treated with vancomycin, Bactrim and Zosyn. The patient's echocardiogram was planned to rule out endocarditis. The patient refused to speak with the medical staff, refused a physical exam, refused lab work and pulled off the lines for monitoring. The patient was discharged (eloped).

This patient is a male with past medical history significant for polysubstance abuse and asthma who presented to the Emergency Department (ED) with complaints of chest/abdominal pain, nausea, vomiting, and diarrhea. The patient was also unable to eat due to tongue lesion. The patient's vital signs on presentation included: Temperature 101.8 F, Blood Pressure 118/58, and Pulse 77, Respiratory Rate 16, and Oxygen (O2) Saturation 97% on Room Air. The patient's laboratory results included the following: sodium 131, glucose 98, lactate 2.3, and troponin negative. The patient was started empirically on intravenous (IV) fluids and antibiotics. The patient's electrocardiogram (EKG) showed sinus rhythm with trigeminy. The patient's chest X-rays revealed (CXR) was negative. Antibiotic coverage was adjusted with the addition of Zosyn and Bactrim. Their clinical impression was chest pain secondary to cocaine use. The patient was monitored on telemetry and plan was to rule out endocarditis with an echocardiogram. Infectious Diseases consulted to find the source of fever. The patient remained afebrile and hemodynamically stable. The patient left the hospital against medical advice (AMA).

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Acute Inpatient Stay.

The insurer denied coverage for the Acute Inpatient Stay.  The denial is upheld. 

This is a female patient with a history of reflux, high cholesterol, and hypertension.  She presented to the emergency room (ER) with complaints of abdominal pain and vomiting. She had a laparoscopic cholecystectomy a couple of weeks earlier.  She was afebrile and the vital signs were stable.  There was no abdominal rebound or guarding.  There was no leukocytosis.  Intravenous (IV) fluids and potassium replacement were given.  A computerized axial tomography (CAT) scan revealed edema at the cholecystectomy site.  The Gastroenterologist advised treatment with Dicyclomine.

Clinical indications for admission for undiagnosed abdominal pain according to Milliman Care Guidelines (MCG) include hemodynamic instability, severe pain that is not responding to medication, peritoneal signs, inability to maintain oral hydration after observation care and the need for a procedure that cannot be performed on an ambulatory basis.  The patient did not have these conditions.

This patient presented with abdominal pain of unclear etiology a couple of weeks after a laparoscopic cholecystectomy.  There was no evidence of an acute infection and no further surgical interventions were needed.  The treatment with IV hydration, Zofran and Dicyclomine could have been given with observation status.  She did not meet MCG criteria for admission for undiagnosed abdominal pain.  The healthcare plan acted reasonably and with sound medical judgment.  An acute inpatient stay was not medically necessary.  The denial is upheld. 

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

Diagnosis: Atypical chest pain.
Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.  The denial is upheld. 

This is a female patient with a past medical history of hypertension who presented to the hospital with atypical chest pain. Upon presentation to the Emergency Department (ED), the patient's vital signs were stable, and her electrocardiogram (EKG) revealed no evidence of acute ST or T wave changes.  The patient's serial troponin testing was within normal limits, and the patient was ultimately discharged the following day.

Based on the review of the medical record, hospital admission was not medically necessary for this patient. This patient presented with atypical chest pain. The patient's pretest probability of coronary artery disease was low. (1) Utilizing the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score, the patient was considered low risk. (2) Utilizing the thrombolysis in myocardial infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (3) 

Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

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

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

Diagnosis: Transient ischemic attack (TIA).
Treatment: Full Hospital Admission.

The insurer denied coverage for the Full Hospital Admission.  The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with subjective numbness of the left face, left arm, and left leg that started 2 hours prior to presentation at the ED.  The patient was sitting and began to experience numbness to the left-side of the body.  The patient described the numbness as pins and needle sensation that affected her face, arm, and leg.  The patient also felt weak at that time on the left-side and had difficulty lifting objects.  Since that time, the patient reported that her weakness had dissipated; the numbness was still present but much improved.  The patient's sister had also told her that her speech was "different".  There were no vision changes and shortness of breath.  The examination revealed the patient was awake, alert, and oriented.  There was no facial asymmetry.  Otherwise, the patient's cranial nerve exam was intact.  There was symmetric strength in the upper and lower extremities.  The sensation was slightly diminished in the left arm and leg.  The numbness was improving.  The patient was admitted to neurology services for a transient ischemic attack (TIA).  The patient's computed tomography (CT) scan of the head without contrast showed no acute infarct or hemorrhage.  The patient was subsequently transferred to a secondary hospital with neurology for work-up of a TIA.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient developed a subjective transitory numbness of the left face, left arm, and left leg.  The patient's neurological examination was normal.  The patient's CT scan of the head was negative.  There was no recurrence of symptoms during this patient's inpatient stay.  According to the patient's records, there is no clear evidence of acute change in the patient's neurological examination suggestive of acute stroke.  There was no documentation of acute motor, sensory or visual deficit that suggested an acute stroke.  There was no clinical instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure that warranted inpatient level of care.  Therefore, the acute inpatient care admission was 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 Full Hospital Admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 

Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.

The denial is upheld. 

This is a female patient with a medical history of anemia who presented to the emergency department (ED) with complaints of vaginal bleeding with associated dizziness, chills, left hand numbness and tongue numbness. Vital signs were stable. Lab work was significant for a hemoglobin of 4.8, hematocrit of 15.3. She was admitted under the Gynecology service for a diagnosis of symptomatic anemia secondary to menorrhagia. The treatment plan included a blood transfusion and sonogram.  The patient received 3 units of packed red blood cells.  Post transfusion, her hemoglobin was 8.3, and her hematocrit was 25.5. A pelvic ultrasound and transvaginal ultrasound indicated an enlarged uterus and large physiologic cyst of the left ovary. The patient was medically cleared for discharge with instructions to follow up with Gynecology.

This patient was symptomatic for anemia. This patient also fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 and she was symptomatic, so transfusion was necessary. Transfusions are done routinely in the outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission nor does a sonogram require admission.

This patient was admitted and transfused. Except for receiving 3 units of packed red blood cells nothing was done in the hospital.

Ideally this patient could have been transfused in the ED, monitored for a few hours, her complete blood count (CBC) repeated and then discharged home with a follow up within 24 hours with her Gynecologist. Nothing was done in the hospital that could not be done as an outpatient.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. This patient did not have any of these. The patient could have been transfused in the observation area and discharged after finishing her transfusion.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The hospital admission is not considered medically necessary for this patient. 

The medical necessity for the hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is overturned. 

This is a male patient with a past history of hypertension, diabetes, coronary disease and depressed left ventricular (LV) ejection fraction who presented to the hospital with symptoms of alcohol withdrawal and subsequently developed chest pain. Following several days of treatment for alcohol withdrawal the patient developed chest pain and was transferred to the telemetry ward to rule out an acute coronary syndrome (ACS).  Upon arrival, physical examination was unremarkable.  Electrocardiogram (ECG) revealed T wave inversions in the lateral leads.  Serial troponin levels were mildly elevated. Echocardiogram revealed a depressed LV ejection fraction (35%) and severe mitral regurgitation.  The patient was treated medically and ultimately discharged following diuresis. 

This patient presented with chest pain. His pretest probability of coronary artery disease is high. Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3).  Using the HEART (History, ECG, Age, Risk Factors, Troponin) score risk stratification schema, this patient would have an intermediate to high risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. Heart failure with reduced ejection fraction, severe mitral regurgitation and history of previous coronary disease requiring revascularization several months prior to presentation all support management at the acute inpatient level.  In conclusion, admission to the hospital was medically necessary. 

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

The medical necessity for the inpatient admission is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (skeletal Class II, with retruded mandible, maxillary and mandibular crowding, deep overbite and severe overjet). 
Treatment: D8080 Braces. 

The insurer denied coverage for D8080 Braces.  The denial is overturned. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, with retruded mandible, maxillary and mandibular crowding, deep overbite and severe overjet. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of overjet greater than 9 millimeter (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides 6 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 claims an automatic qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet the insurer and the plan criteria to justify orthodontic care.

The coverage for braces and treatment visits is considered medically necessary for this patient. 

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

Based on the above, the medical necessity for D8080 Braces is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Abdominal pain. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient presented to the emergency department with three days of non-radiating right lower quadrant abdominal pain, vomiting, and diarrhea which became black. He reported a fever three days prior. He had been using Pepto-Bismol. Vital signs were notable for elevated blood pressure of 149/112 millimeter of mercury and elevated pulse rate of 102 beats/minute. Physical examination was notable for right lower quadrant tenderness, mild epigastric and left upper quadrant tenderness, and brown stool on rectal exam. Labs showed elevated white blood cell count of 11.9 thousand. Computed tomography scan of the abdomen and pelvis showed long segment wall thickening of the distal ileum compatible with enteritis, likely infectious or related to inflammatory bowel disease, associated small to moderate free intraperitoneal fluid, mildly thickening appendix without appearance of primary inflammation, lack of bowel obstruction, and hepatic steatosis. He was treated with intravenous fluids, ondansetron, morphine, famotidine, Zosyn, and oral Tylenol. Gastroenterology consultation concluded that he had likely infectious gastroenteritis, and recommended infectious diarrhea panel and symptomatic treatment, with consideration for inpatient versus outpatient colonoscopy. General Surgery consultation concluded that there was unlikely appendicitis, and recommended advancing diet to regular, infectious stool work-up, and likely discharge home that day. He was discharged on Augmentin for three days, with a plan for Primary Care and Gastroenterology follow-up. 

The inpatient stay is not supported as medically necessary. The patient had symptoms  consistent with infection and imaging showing enteritis. The standard of care for the evaluation of gastroenteritis was appropriately performed [1-5]. There was concern for possible infection, but this was not definitively established. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented either [6]. Although gastroenteritis was possible, there was no evidence for acute inflammatory bowel disease with complications or other causes which might warrant the inpatient level of care, and colonoscopy as inpatient was not determined necessary [4,5]. Based on the available information, the care which was undertaken could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sepsis/Urinary tract infection.

Treatment: Full Hospital Admission.

The insurer denied coverage for the full hospital admission.

The denial is upheld. 

This is a male patient with a past medical history of hypertension (HTN), benign prostatic hypertrophy (BPH), pre-diabetes, and subdural hematoma.  The patient presented to the Emergency Department (ED) complaining of fever to 104 degrees Fahrenheit, was status post a Middle Meningeal Artery (MMA) embolization procedure, and was discharged with a Foley in place.  The patient's Foley was removed on the day prior to presentation to the ED.  The patient then had to void every two hours that night.  The patient had stable vitals in the ED, and was afebrile.  Urinalysis was positive.  The patient was admitted to Medicine with a diagnosis of sepsis/urinary tract infection - the patient was given intravenous Rocephin.  Urine cultures grew Serratia species.  The patient had mild hypotension which responded to intravenous (IV) fluids.  The patient failed to void successfully, catheter was in/out four times for trial of void (TOV).  The patient was discharged home with Foley in place and outpatient follow-up.  The patient was on Flomax/Finasteride at the time of discharge.

Per Milliman Care Guidelines (MCG) Health (24th Edition) Urinary Tract Infection (UTI), the patient fails to meet clinical indications for admission to inpatient care.  There was no hemodynamic instability, persistent or severe vomiting, altered mental status, new onset coagulopathy, or acute renal failure.  The patient does meet findings for Observation Care: Vital signs abnormality (low blood pressure which responded to intravenous fluids), Suspected urinary system obstruction (stone, enlarged prostate).

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

The carrier's denial of coverage for the full hospital admission is upheld.  The medical necessity is not substantiated.