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

Diagnosis: Seizure
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult male who was seen at the emergency department for tonic-clonic seizure like activity. He was alert and oriented on presentation and described as having possible syncope. Computed tomography (CT) of the head on admission showed no abnormalities. Magnetic Resonance Imaging (MRI) brain showed no abnormalities.

In this case, the patient had normal mentation. There were no unstable vitals. There were no abnormalities on exam or imaging. The inpatient hospital admission was not necessary. The patient's care could have been managed on a lower level of care such as observation.

Morris J. (2021), "Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% (percent) of all emergency department visits and $ (dollars) 5.6 billion in healthcare costs annually. In a very small subset of patients, syncope may be a warning sign for serious outcomes or death, but identifying these patients is challenging, as the emergency clinician must distinguish between life-threatening causes and the more common, benign etiologies. Low-yield and expensive testing is often performed, even for benign presentations. Much research on syncope is observational, and clinical decision rules frequently perform poorly in validation studies. This issue reviews the clinical and diagnostic findings that are useful for safely and efficiently identifying patients presenting to the emergency department with syncope."

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

Diagnosis: Ruptured hemorrhagic cyst 
Treatment: Inpatient hospital admission 
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 

According to the documentation submitted, this is an adult with no significant history. The patient presented to the emergency room (ER) with complaints of abdominal pain after a diagnostic laparoscopy for evacuation of hemoperitoneum and cauterization of a ruptured hemorrhagic cyst. A transvaginal ultrasound (TVUS) was concerning for a hemoperitoneum. Vitals were stable. Serial abdominal examinations were done, and labs were drawn. Human chronic gonadotropin (HCG) levels down trended. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient has bleeding from an ovarian cyst. The patient was not unstable. There were no unstable vital signs that did not improve or other findings warranting an inpatient hospital admission. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Obstetric and Gynecologic Disease. 

There was a concern for a hemoperitoneum. The patient was medicated as ordered. Serial abdominal examinations were done, and labs were trended. The requested admission was warranted based on Milliman Care Guidelines 26th Edition using the guideline of Gastroenterology.

The patient presented to the ER with complaints of abdominal pain after a diagnostic laparoscopy for evacuation of hemoperitoneum and cauterization of a ruptured hemorrhagic cyst. 

A TVUS was concerning for a hemoperitoneum. Vitals were stable. Hematocrit was stable. There was no need for blood transfusion. Serial abdominal examinations were done, and labs were drawn. HCG levels down trended. 

The patient presented after surgery complaining of abdominal pain. Vitals and hematocrit were stable. The patient could have been managed at the observation level of care without the need for admission. Once the provider ascertained that there was no evidence of bleeding, the patient could have been sent home. It is unclear why the patient was admitted as serial hematocrits and vital signs monitoring does not require hospital admission. Note that patients with hemodynamic instability require immediate surgical management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, 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: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces; D8670 Monthly Visit
The insurer denied: D8080 Braces; D8670 Monthly Visit.
The denial is overturned.

The patient is an adult female. The request is for orthodontic benefits with monthly visits. She has a Class I skeletal malocclusion. She has moderate upper jaw spacing and mild lower jaw spacing, with a deep bite. The patient is missing upper right lateral incisor.

The D8080 Braces; D8670 Monthly Visit are medically necessary.

The patient has a crossbite of an anterior tooth (#6, upper right permanent canine) with the lower tooth #26 (lower right permanent lateral incisor). There is gingival (gum) attachment loss present. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this, and the monthly visits are necessary to make sure the treatment is progressing properly. The case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic aseptic necrosis of the left femur.
Treatment: Long term custodial care.

The insurer denied coverage for long term custodial care.  The denial is overturned.
 
The patient was diagnosed with idiopathic aseptic necrosis of the left femur, cerebral cryptococcosis, and difficulty walking. The records note the patient is profoundly weak, unable to tolerate a regular consistency diet, being prescribed a thin liquid diet, and is total assist for self-care and functional transfers. It is noted the patient's hemodynamics are stable. The request is for long term custodial care, which is under review. This patient required more care than the home setting would allow.

The patient was involved in a program of physical and occupational therapy once pain medications gave her some measure of relief from her hip pain. Specifically, she received physical therapy (PT) for idiopathic aseptic necrosis of left femur; cerebral cryptococcosis and difficulty in walking, not elsewhere classified. Occupational therapy (OT) began one month later for toilet transfer, grooming and bathing and dressing. Patient was receiving PT (physical therapy) and OT (Occupational therapy) with "skilled interventions, therapeutic exercise, therapeutic activities, neuromuscular re-education, self-care training, Wheel Chair management".

There was documentation that the patient had deficits in balance: not steady and only able to stabilize with staff assistance: when moving from seated to standing position, when transferring between surface, and when moving on and off toilet. She was noted to be incontinent of bladder and continent of bowel. Patient has deficits in walking and was only able to stabilize with staff assistance.

Long term custodial care was medically necessary for this patient.

Mayer, et al., "In the United States, we are blessed with many options for post acute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports."

"Conclusions: High intensity therapy was associated with desirable discharge outcomes and may shorten skilled nursing facility (SNF) length of stay. Despite growing reimbursements to SNFs for rehabilitation services, there may be desirable benefits to beneficiaries who receive high intensity therapy." (O'Brien, et al.).

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 long term custodial care is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hearing loss
Treatment: Durable Medical Equipment - Hearing Aids
The insurer denied the durable medical equipment - hearing aids.
The denial is upheld.

The patient is an adult male for whom coverage of hearing aids is the subject of review. There is a bilateral high frequency SNHL (sensorineural hearing loss) documented on audiogram. The provider is requesting bilateral hearing aids. The request was previously denied by the health plan as not meeting Plan criteria. The denial is being appealed.

The requested health service is not medically necessary.

The patient is reported to have a high frequency bilateral SNHL. This is documented on audiogram. However, there is no medical exam provided documenting the physical status of ears. Therefore, based on the information provided, the medical necessity of the bilateral hearing aids is not confirmed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bradycardia, paranoid delusions
Treatment: Inpatient Hospital Admission:
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This adult male was hospitalized for bradycardia. He presented to the emergency department for evaluation of paranoid delusions. His past medical history is remarkable for concussion five months prior. The patient's vital signs were remarkable for a heart rate of 99 and blood pressure of 148/95. Later, the patient's electrocardiogram (EKG) showed junctional bradycardia with a heart rate 39-46. Treatment included Zyprexa, cardiology and electrophysiology (EP) consultation with negative workup. The patient was deemed medically stable and discharged to an inpatient psychiatry unit. The requested coverage for inpatient hospitalization was denied based on the policy and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer reviewed medical literature, including the Milliman Care Guidelines (MCG) Cardiology GRG (Guidelines Review Group), criteria for inpatient admission are not met, including hemodynamic 
instability, bradycardia that is symptomatic and is not readily reversible, atrial ventricular conduction abnormality as indicated by cardiac injury, such as cardiac contusion requiring monitoring or treatment beyond scope of observation care, symptomatic first-degree, second-degree or third-degree atrioventricular block not readily reversible or other conduction abnormality with need for inpatient care or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including monitoring for asymptomatic, transient bradycardia in the setting of primarily acute paranoid delusions is routinely provided safely effectively at a lower level of care. Therefore, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

According to the documentation submitted, this is the case of a patient with a history of diabetes mellitus, hyperlipidemia, and protein C deficiency. The patient presented to the Emergency Department (ED) after a fall. The patient was admitted to medicine for syncope. Prior to completion of the inpatient treatment plan and workup, the patient decided to leave against medical advice (AMA).

The hospital stay was for treatment of fainting. The tests were normal. There were no signs of a significant head injury. The hospital stay was not medically necessary. 

The provider states that the patient was seen in the ED due to acute recurrent syncope associated with fall, head trauma, intermittent confusion, and recent vomiting. Electrocardiogram (EKG) showed normal sinus rhythm (NSR). Computed tomography (CT) head/cervical spine and angiogram of chest showed no acute findings. The patient was administered intravenous (IV) fluids and IV medication. The diagnostic studies could have been done in observation or as outpatient.

The history and physical stated the patient was seen after a fall. The patient has had multiple admissions for similar events. The trauma note says the patient had syncope. The patient was without further events and the patient stated they would like to go home and is leaving. 

"Syncope is a transient loss of consciousness and postural tone followed by spontaneous recovery. While there are numerous classification schemes used to further identify and manage underlying conditions that may lead to syncope, syncope ultimately results from decreased cerebral perfusion. Syncopal episodes may occur suddenly and without preceding signs or symptoms or may be preceded by dizziness, lightheadedness, diaphoresis, nausea, visual disturbances, or other signs and symptoms. Patients may describe syncopal events in a wide variety of ways, some of which include fainting, blacking out, falling out, having a spell, or losing consciousness. Syncope is responsible for 1 to 3.5 percent of all emergency department visits and 6 percent of all hospital admissions in the United States. Underlying conditions that may cause decreased brain perfusion and lead to syncope can range from benign to life-threatening." (1)

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, 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: Presyncope. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

This is a female patient with a past medical history (PMH) of hypertension (HTN) who was admitted with complaints of (c/o) presyncope after standing. The vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for negative troponin. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without (w/o) ischemic changes. The patient was diagnosed with presyncope and treated with cardiac monitoring, transthoracic echocardiogram (TTE), and a computed tomography (CT) scan of the head. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care. 
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) syncope associated with standing. The patient did not have structural heart disease, hematopoietic cell transplantation (HCT) less than (<) 30, hypotension, or family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, QT interval abnormalities or conduction blocks. The patient did not have subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma or cardiac arrest, or exertional syncope. The patient was diagnosed with presyncope and treated with cardiac monitoring, TTE, and CT scan of the head. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history (PMH) of latent tuberculosis (TB), hepatitis B virus (HBV), previous acute portal vein thrombosis (PVT), and cirrhosis status/post (s/p) deceased donor liver transplantation (DDLT) who was admitted with complaints of (c/o) an acute kidney injury found on outpatient labs. His physical exam was notable for no apparent distress (NAD), awake, alert, oriented times three (AAOx3). Lab work was notable for creatinine 1.9 (baseline 1.2). Imaging studies included a computed tomography (CT) scan of the chest which showed improving ground-glass opacities and nodules. The patient was diagnosed with an acute kidney injury, possibly related to voriconazole, and treated with intravenous fluids (IVF), holding diuresis and voriconazole. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) after being found to have an acute kidney injury on outpatient labs, for which IVF were administered and medications were held and the patient's creatinine responded. This patient did not have hypertension (HTN) requiring continuous vasoactive medication, had no concomitant febrile illness, and there was no urgent indication for dialysis, marked electrolyte abnormalities, volume overload, severe hyponatremia, hyperkalemia, severe metabolic acidosis, or acute respiratory distress, while the glomerular filtration rate (GFR) reduction was less than 50 percent (%). This patient without distress was admitted for acute kidney injury, received IVF, and was discharged home in stable condition, and this could have been provided safely at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted urethral stone. 
Treatment: Inpatient admission. 
The insurer denied coverage for the inpatient admission. 
The denial is upheld. 
 
This is a patient who was brought to the hospital for treatment of an impacted urethral stone. Patient was taken to the operating room for cystoscopy, laser lithotripsy of stone in urethra, removal of stone fragments and catheter placement. Patient tolerated the procedure well with no complications under general anesthesia. Patient recovered well after the procedure, was sent home later that day. The insurer has denied coverage for as an inpatient admission. They stated patient had no acute/ unstable medical problems and had an uncomplicated procedure. The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guidelines (MCG) Health (26th): 

Urologic surgery or procedure patient meets the discharge parameter within 24 hours post procedure. As per the guidelines, this procedure is performed in the ambulatory surgery setting. 
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 an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- urinary retention
Treatment: Inpatient admission
The health plan denied: Inpatient admission
The determination is: Overturned 

The patient is a male who presented due to lack of urination for 2 days. He was well until 2 days prior to presentation when he stopped making wet diapers. He typically had 6 wet diapers per day. He was not complaining of any pain, was acting well, and drinking normally. His bowel movements had been normal, but he continued to not have any wet diapers, so he was brought to the emergency department for evaluation. In the emergency department a bladder ultrasound was performed which showed a distended bladder that was full of urine. A straight catheterization was performed and a large volume of urine was drained with some urine leaking out of the sides of the catheter. A urine culture was sent and laboratory values were obtained. He was admitted to the hospital for evaluation of urinary retention and repeat catheterization with a urology consultation as needed. His intake and output measurements were monitored. He subsequently had a large number of wet diapers and continued to drink well. By the following day, he was felt to be stable for discharge to home with follow-up as an outpatient.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient hospital admission was medically necessary for this patient. This is a young male who presented with urinary retention. He had a large volume of urine in his bladder when straight catheterization was performed. The etiology was unclear, and the differential diagnosis included obstruction, infection, and posterior urethral values, all of which would require prompt intervention. Therefore, hospitalization was indicated for specialist consultation, evaluation of urinary obstruction, close monitoring with potential repeat catheterization, ultrasound, and additional treatment as needed that would require inpatient care.