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

This patient presented to the Emergency Room (ER) with an asthma exacerbation. Past medical history (PMH) includes asthma, recurrent urinary tract infections (UTI), eczema, and allergies. In the ER, the patient was found to be tachypneic with decreased air entry and bilateral rhonchi, as well as pallor. The patient was admitted to the hospital for further management of status asthmaticus, and initially received albuterol treatments every 2 hours. The patient improved during the hospitalization, and had weaned to every 4 hour treatments and was felt to be stable for discharge to home. The health plan's determination is overturned.

This is a patient who presented with status asthmaticus. The patient continued to have significant symptoms despite appropriate treatment as an outpatient, as well as aggressive treatment in the ER. The patient initially required continuous albuterol therapy and was still receiving every 2 hour treatments at the time of admission.
The decision making at the time of admission was consistent with the patient's age, the presence of an asthma exacerbation requiring intensive treatment, the continued need for frequent bronchodilator treatments (initially every 2 hours on admission) which requires inpatient care, and the need for close monitoring for potential deterioration of his clinical status and further treatment, if needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, substance abuse

Treatment: Inpatient admission, evaluation and medication management.

The insurer denied inpatient mental health treatment. That denial was reversed

This patient was admitted to inpatient mental health residential treatment due to depressive symptoms, behavioral issues, and substance use. She had poor hygiene, sleeping problems, decreased appetite, isolation, loss of interest and decreased motivation, concentration problems, and had past suicidal ideation. She had reports of panic attacks, worrying, restlessness, hoarding, and somatic complaints. She had agitation, verbal aggression, and impulsivity, and past self-injurious behavior by cutting. She was using cannabis and tried stimulants, Xanax, and opiates. It was reported that she had an overdose in the past with Xanax. She had avoidance and poor insight. She had reported diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, ADHD, and Cannabis Use Disorder. She reportedly had individual and group therapy. 

The APA Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this was a high risk patient who continued to minimize the risk of her substance use and who had a previous overdose from Xanax who had with poor coping skills and poor insight with rigid thoughts. 

Notes reported that she still had rigid thought patterns, was rationalizing the use of substances and planned to continue using cannabis, was unable to engage in meaningful discussion about the risks and consequences of substance use. She needed more time in this setting to work on her cognitive distortions, develop coping skills to identify and counter negative thoughts, and improve insight into the risks and consequences of her substance use and how it affects her mood and behaviors. Continued inpatient mental health residential treatment was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of hypertension, diabetes mellitus, Roux-en-Y gastric bypass, and cholecystectomy. She presented to the emergency department from Urgent Care on 01/07/19 with severe bilateral upper abdominal pain radiating from back to front (worse with respiration and movement) and fever to 103 degrees Fahrenheit (F), palpitations, chills, sweats, nausea, and diarrhea. The health plan's determination of medical necessity is upheld, in whole. The patient had symptoms consistent with gastroenteritis, which had resolved before presentation to the emergency department; imaging showed no acute process, and there was no suspected or established complication such as gastrointestinal perforation, pancreatitis, intra-abdominal abscess, toxic megacolon, bowel obstruction, ongoing gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypergylcemia, Ketonuria, and depression
 
Treatment: Inpatient admission, evaluation, and medication management

The insurer denied coverage. The denial was upheld. 

This adult male patient with a history to include diabetes as well as peripheral neuropathy, psychotic disorder, and herniated disc who presented to the emergency department complaining of abdominal pain with nausea/vomiting, and constipation.  The patient complained of pain rated at a 9/10 with constipation.  The patient was not eating well and was non-compliant with medications.  Objectively, the patient had normal vital signs upon presentation.  The patient was alert and oriented and in no distress.  There was evidence of a sensory deficit to his feet. However, there was 5/5 strength.  The recommendation was made for the patient to undergo laboratory and diagnostic studies.  The patient did have evidence of ketones in the urine.  The patient's serum glucose was 306 and the anion gap was 20.  The patient had a venous pH of 7.38.  The chest x-ray revealed no focal infiltrates and no active pulmonary disease.  The patient did receive treatment while in the emergency department showing improvement in the anion gap.  The patient's anion gap did decrease to 11.  It was recommended the patient be admitted for further treatment.  The documentation indicated he has also been sad and depressed.  He stated he had been crying frequently; however denied suicidal ideation.  He continued with treatment and the importance of medication compliance was reinforced.  The patient also underwent a psychiatric evaluation and was discharged with instruction to follow-up.

Within the documentation it was noted that the patient did have hyperglycemia as well as ketonuria and evidence of an anion gap of greater than 12.  However, there was a lack of documentation to support this patient had acidosis as evidenced by an arterial venous pH of less than 7.30.  Furthermore, it was noted within the submitted documentation that this patient's condition quickly improved after initial treatment. Inpatient admission was not necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for bipolar disorder, iron deficiency anemia and spondylosis of L5/S1. The patient was recently discharged after undergoing an elective decompressive laminectomy and fusion. The patient was doing well in regards to his spinal procedure but began experiencing redness and swelling that began in his feet bilaterally and progressively spread up both bilateral lower extremities to his knees. 

The health plan's determination is upheld. The inpatient hospital stay during was not medically necessary. This patient was an otherwise healthy non-diabetic patient. Standard of care would be to attempt outpatient oral therapy with an initial episode of cellulitis when the patient presents hemodynamically stable. The patient did have an elevated ESR and CRP level documented which could have possibly affected the admitting team but in the presence of a recent surgery this is unreliable. In addition, it is better used to follow in the presence of osteomyelitis which was not present in this patient. This known fact was also reinforced by consulting providers that these values were most likely a result of the recent surgical procedure. Lower extremity edema, or a single abnormal lymph node found incidentally on a venous doppler are not issues that require an inpatient admission to the hospital.
This patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission, diagnostic evaluation, and medication management.

The insurer denied inpatient admission. That denial was upheld.

This child had been sick for 2 weeks with a sore throat, fever, decreased appetite, and coughing. There were sick contacts in the school and the school recommended to the be brought to the doctor for an evaluation. There was a history of some vomiting at home.

In the ER the child was noted to be afebrile, breathing comfortably with normal pulse oximetry and vital signs, although she was described as being congested. There was no wheezing noted or evidence of respiratory distress. The physical examination and urinalysis did not demonstrate evidence of dehydration. A chest x-ray was significant for left lower lobe pneumonia and a test for influenza B was positive. White blood count was not elevated but the serum potassium was low at 3.3. The child received one dose of albuterol and atrovent and was started on IV fluids and ceftriaxone via the IV. The child was also started on azithromycin and tamiflu by mouth. The decision was made to admit her to the hospital with a diagnosis of pneumonia for continue treatment with IV fluids and antibiotics. 

This patient was treated appropriately in the ER for pneumonia in the left lower lobe which was diagnosed on chest x-ray. The child was also started on tamiflu for the influenza virus. The child was not dehydrated or in any respiratory distress and was able to tolerate oral medication in the ER. She could have been safely discharged to continue oral medications for pneumonia and influenza B with a follow up visit with the pediatrician in 24 to 48 hours. The decision to admit to the hospital was not consistent with the standard of care for treatment of pneumonia in a child this age.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematuria

Treatment: Inpatient stay

Summary:
The patient's care could have been provided at a lower level of care.  He was afebrile and hemodynamically stable throughout the hospitalization.  There were no signs of sepsis.  Throughout the admission, there were no unstable vital signs reported. He did not have kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  IV antibiotics and IVF in a stable patient with a known prior urine culture and sensitivity can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was admitted to the hospital with a pre-syncopal episode, which was likely vasovagal from the manipulation of the Foley catheter. He remained in stable condition and was discharged home.
The health plan's determination of medical necessity is upheld in whole. The San Francisco Syncope Rule, is a risk stratification tool. It predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope. Based on the calculations, this patient received 0 points. This means that the patient was in the low-risk group for a serious outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg pain and swelling

Treatment: Inpatient admission, diagnostic evaluation, and medication management

The insurer denied inpatient admission. That denial was upheld

This patient presented to the Emergency Department with complaints of left leg pain and swelling. The patient's vital signs on presentation included: a temperature of 36.7C, a blood pressure of 122/70, a pulse of 83, a respiratory rate of 20, and an oxygen saturation of 96%. Laboratory values were notable for the following: a white blood cell (WBC) count of 4.6, a hemoglobin of 13.3, a hematocrit of 39.6, a creatinine of 0.96, a glucose of 98, and a lactate of 1.4. 

The patient was admitted for possible left leg cellulitis. He was empirically started on intravenous antibiotics (Unasyn). An x-ray of left knee and bilateral feet were negative. A chest x-ray was also negative.  A duplex ultrasound was negative for deep vein thrombosis (DVT). This patient remained afebrile, hemodynamically stable and improved clinically. He was discharged to continue oral antibiotics (Augmentin) as an outpatient.

According to the documentation, the patient presented with left lower leg pain and swelling. Otherwise, he was afebrile, hemodynamically stable, and with unremarkable laboratory results, including his WBC count. There was no evidence for systemic infection. Based on the above findings, the patient was stable for outpatient management following evaluation in the Emergency Department.
Appeal type: Medical necessity
Decision: Upheld

The patient past medical history of asthma and recent treatment for community acquired pneumonia presented to the hospital with chief complaint of nausea, vomiting, lightheadedness, fatigue, and feeling that  sense of rotation was off. Additional history was significant for the patient having recently undergone cardiac catheterization in the setting of 2 episodes of syncope which was unremarkable, as well as Holter monitoring. 

On presentation to the emergency department, vital signs were within normal limits. Exam otherwise was significant for cardiac, pulmonary, and neurologic exams within normal limits. Labs were drawn which showed leukocytosis of 12.1, lactic acid of 2.3 with repeat 1.4, and complete blood count (CBC), basic metabolic panel (BMP), and troponin otherwise grossly within normal limits. Urinalysis showed large leukocyte esterase but was contaminated with 21 epithelial cells. Chest x-ray (CXR) revealed no acute process. Electrocardiogram (EKG) showed sinus bradycardia. Computed tomography (CT) of the abdomen/pelvis showed distended gallbladder without evidence of wall thickening, uterine fibroids, bilateral renal cysts, liver lesion consistent with hemangioma, and partially calcified nodular opacity in the left breast. CT of the head showed no obvious abnormality. Given concerns for vertigo, leukocytosis, lactic acidosis, and systemic inflammatory response syndrome (SIRS), the patient was started on intravenous (IV) fluids, given IV antibiotics, and subsequently admitted to the hospital.  The health plan's determination is upheld.

This patient presented with SIRS criteria with nausea, vomiting, and generalized weakness. The patient did not have clear infection present on admission, cardiac ischemia, cerebrovascular accident (CVA), or obvious other acute process contributing to the symptoms. The patient did not have acute kidney injury or other evidence of organ dysfunction. Lactic acidosis normalized within two hours of presentation. The patient was not noted to have had recurrent vomiting or inability to take PO. This patient with SIRS and nausea was appropriate for hospital treatment but did not require care at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Euflexxa injections

The bilateral Euflexxa injections are not medically necessary.

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis (OA) if all other courses failed prior to surgery. 

However, the recommendations for use of viscosupplementation have changed. 

A review of the Clinical Practice Guideline (CPG) by the American Academy of Orthopedic Surgeons (AAOS) cites:

The 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads: We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from three high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.)

The Orthopedic group reports "strongly do not recommend use".

The denial would thus be appropriate and consistent with current practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough and abdominal pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The patient did not fail outpatient antibiotic therapy and did not have fever, hypoxia, carbon dioxide retention, pleural effusion, or empyema.  The patient did not have hyperkalemia, uremia, acidosis, or volume overload.  Hemodialysis was performed without complication.  There was no evidence of acute intra-abdominal process, and endoscopic or surgical intervention was not required.  The PSI (pneumonia severity index) score was II; the sodium was on presentation calculated to 133 when the glucose of 336 was considered.  There CURB65 (confusion, BUN, respiration rate, BP, Age 65+) score was one.  
In summary, inpatient admission was not medically necessary.  The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Patient who presented with grade II Astrocytoma. The patient underwent a subtotal resection. The patient was recommended adjuvant radiation therapy (RT) using Proton beam. The requested health service/treatment of PBT: Proton Beam Therapy is not medically necessary for this patient. The health plan determination is upheld in whole. Proton beam is being evaluated under The National Cancer Institute (NCI) sponsored trials. Currently there is insufficient clinical data to discern whether treatment with proton beam offers a clinical benefit compared to conventional photon beam treatment. National Comprehensive Cancer Network (NCCN) guidelines do not support the routine use of proton beam in the treatment of CNS malignancies.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history of chronic ethanol (EtOH) abuse for more than one year, who presented to the emergency room for symptoms of recurrent bleeding gums accompanied with episodes of shortness of breath and palpitations. 

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. This patient presented with gingival bleeding, profound symptomatic anemia (Hb=5.3), and thrombocytopenia likely due to bone marrow suppression due to ETOH toxicity. Despite receiving 2 units of packed RBCs (red blood cells) on the day of admission and showing good response on 1/2/19 (Hb=8), her hemoglobin dropped again on 1/3/19 (Hb=6.1) and she required 2 more units of packed red blood cells. This patient was experiencing acute blood loss anemia which required transfusions and inpatient medical care.
Appeal type: Medical necessity
Decision: Upheld

This patient has been diagnosed with metastatic colon cancer with liver and peritoneal metastases. The documentation indicated the patient was noted to have a terminal illness and recommended for hospice care. The patient previously developed a small bowel obstruction and remains unable to tolerate oral intake. The patient was receiving total parenteral nutrition and has less than 6 months life expectancy. The patient was receiving care to include a Nasogastric (NG) tube. However it was removed on 05/21/2019. A Peripherally inserted central catheter (PICC) line was to be placed. The patient was not a candidate for surgery. It was noted the patient had very limited options for further chemotherapy and it was requested at this time that the patient follow-up with palliative care. It was recommended he be transferred for inpatient end of life services. 

The insurer denied acute inpatient care at Calvary Hospital. 

The insurer's denial is upheld.

According to current literature, inpatient palliative or formal inpatient hospice patient care may be indicated when there is evidence of severe uncontrolled symptoms such as pain, fatigue, nausea vomiting or dehydration, gastrointestinal obstruction, confusion, large-volume hemoptysis, agitation, respiratory distress, and/or severe psychiatric findings or there is evidence of no available caregiver. There must also be documentation that the patient's situation is unmanageable at any other level of care such as with respite care at home or a recovery facility. The submitted documentation does not detail the above. The patient had the NG tube removed on 05/21/2019 and there was no documentation to support the patient had severe uncontrolled symptoms such as pain, fatigue, nausea, vomiting or dehydration or continued evidence of a gastrointestinal obstruction. There is no documentation indicating the patient's situation cannot be managed at another level.  

There is no documentation to support the patient has acute care needs that can only be provided at the requested Calvary Hospital hospice acute level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient had a suspicious lesion found on the left thigh, for which Reflectance Confocal Microscopy (RCM) was performed with the results of a melanocytic Compound Nevus. The use of the RCM is under review.

The health plan's determination is upheld. The Reflectance Confocal Microscopy is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Although Reflectance Confocal Microscopy (RCM) is an interesting non-invasive and new form of evaluating pigmented lesions suspicious for potential malignancy, it is not standard of care at this time as per all modern dermatology literature reviews. Accordingly, the clinical utility and appropriate use of RCM remains uncertain, and both clinical bias and subjective training/interpretation of the results of RCM further confound any standard and likely method to utilize that technology for early and timely diagnosis of potential cutaneous malignancy. As such, RCM is not proven to be more beneficial than clinical observation.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient who presents for a skin check. The provider requests coverage for Reflectance Confocal Microscopy. This was denied by the health plan and is under review.

The health plan's determination is upheld. The Reflectance Confocal Microscopy is not likely to be more beneficial any standard treatment for the patient's condition. Reflectance confocal microscopy (RCM) is a novel technology that provides noninvasive, in vivo imaging of the skin at nearly histologic resolution. In one study, the presence of bright cells in a pagetoid pattern on RCM imaging led to a false-positive diagnosis of melanoma in 24 of 39 cases assessed. It is often not possible to distinguish severely dysplastic nevi from malignant melanoma.