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

Diagnosis: Hyperkalemia.
Treatment: Inpatient Admission.
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a female with a past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), hyperlipidemia (HLPD), single kidney, and recurrent urinary tract infections (UTI's). She was admitted with an abnormal potassium of 6.5 without any complaints. Her vital signs were unremarkable. The physical examination was notable for no apparent distress (NAD). The laboratory work (lab work) was notable for creatinine 2.14 (Baseline 1.9), on report her potassium was 6.5 but her potassium was 5.1 on admission.
The chest x-ray (CXR) showed no acute pathology. The renal ultrasound (US) showed no acute pathology. The electrocardiogram (EKG) showed normal sinus rhythm (NSR) without acute ischemic changes, no hyperkalemia changes. The patient was diagnosed with hyperkalemia and treated with Lokelma, intravenous fluids (IVF), and a hyperkalemia cocktail . Urology was consulted and recommended no surgical intervention. The patient was discharged in stable condition.

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

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) an abnormal potassium on lab work without any complaints, however on admission the potassium was found to be within normal limits (WNL). The patient was found to have hyperkalemia the following day without EKG changes and was treated with a hyperkalemia cocktail, which quickly decreased the potassium levels, and intravenous (IV) fluids to treat the slightly elevated creatinine above baseline, to which the patient also responded. The repeat EKG's did not demonstrate any acute changes. The patient did not have any dangerous arrythmias, EKG changes, or chest pain. This patient was treated with a hyperkalemia cocktail, IVF, and expert consultations, and biochemical monitoring, all of which could have been safely provided at an observation level of care.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld.

The patient is an adult male. He presented to the ED (emergency department) of the facility with the report of worsening bright red blood per rectum for the preceding two weeks with fatigue. The patient then developed dizziness and lightheadedness. The patient had formed bowel movements with clots as well as bright red blood. He felt something bulging from his anus, which he was able to self-reduce. The patient had recently undergone Helicobacter pylori treatment with his gastroenterologist.
The presenting hemoglobin was 6.2. The patient received blood transfusions twice and stabilized. Only supportive care was provided, and the patient was discharged on day #4. No procedures, surgery or endoscopy was performed during this stay.

The Inpatient Hospital Admission was not medically necessary.

While the care as provided was medically appropriate, the level at which the care was provided was not medically necessary. The care consisted of two units of blood. There were no procedures or surgery undertaken. Therefore, despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had bleeding from a rectal pathology; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO (nothing by mouth) 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 in its entirety.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting; Nausea; Abdominal pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female with a medical history of Helicobacter pylori gastritis. The patient presented to the ED (emergency department) of the facility with the complaints of severe, progressive, intractable nausea with emesis. The patient received supportive care and IV (intravenous) anti-nausea medication and hydration. The patient was admitted to an acute level of care.

The Inpatient Hospital Admission was not medically necessary. 

While the care in its entirety was medically appropriate, the level at which the care was rendered was not medically necessary. 
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had nausea with vomiting; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) 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. As such, the plan acted reasonably, with sound medical judgment, and in the best interest of the patient in its denial of coverage of the inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Issues.
Treatment:  Braces and Monthly Visits.

The insurer denied the braces and monthly visits.  The health plan's determination is upheld.

The patient is a male with a Class I malocclusion, moderate maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The subject to be determined is if the requested health service/treatment of braces and monthly visits are medically necessary.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The treatment for braces and monthly visits is not medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5 millimeter (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces are not medically necessary.

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: central sleep apnea
Treatment: Pace Maker Device (Phrenic Nerve Stimulation) 
The insurer denied Pace Maker Device (Phrenic Nerve Stimulation). 

The health plan's determination is overturned.

The patient is a man with a history of hypertension, hyperlipidemia, myocardial infarction, obesity and primary central sleep apnea syndrome. Polysomnography revealed severe sleep apnea with an apnea hypopnea index (AHI) of 66.5/hour; the majority of events were central. There were oxygen desatruations to a minimum of 85% (percent). The patient's symptoms include daytime hypersomnolence, fatigue, and difficulties with memory, concentration and mood.

The Pace Maker Device (Phrenic Nerve Stimulation) is medically necessary for this patient.
This patient has severe symptomatic central sleep apnea (CSA). The Remede System is a fully implantable system that is implanted transvenously for phrenic nerve stimulation and treatment of CSA. Its use is patients with CSA has been shown to be safe and to result in sustained improvements in key sleep parameters, sleep symptoms and quality of life. It is Food and Drug Administration (FDA) approved for the treatment of moderate to severe central sleep apnea. Unlike with obstructive sleep apnea, continuous positive airway pressure (CPAP) is of limited benefit in CSA. The use of the Pace Maker Device (Phrenic Nerve Stimulation) is medically necessary in this symptomatic patient.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a medical history of gastroesophageal reflux disease (GERD). She presented to the emergency department with epigastric abdominal pain for a week, and vomiting. Her vital signs were notable for low blood pressure of 99/63 millimeters of mercury (mmHg). The physical examination was notable for a soft, nondistended abdomen with epigastric tenderness. Testing for coronavirus 2019 (COVID-19) was positive. A computed tomography scan of the abdomen and pelvis showed a normal pancreas and lack of biliary dilation. She was treated with intravenous famotidine, ondansetron, ketorolac, and fluid, and oral Maalox. She was made nil per os. A gastroenterology consultation noted elevated liver enzymes and a positive COVID test; the recommendation was magnetic resonance cholangiopancreatography to rule out choledocholithiasis, follow liver enzymes and acute hepatitis panel, daily proton pump inhibitor, and avoid non-steroidal anti-inflammatory drugs (NSAIDs). She had markedly improved but persistent intermittent epigastric pain. Magnetic resonance cholangiopancreatography showed an unremarkable post-cholecystectomy exam. She was discharged with a plan for primary care and gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care is not medically necessary.
The patient presented with symptoms and elevated liver enzymes consistent with biliary obstruction, and pancreatitis was suspected. However, she did not have evidence of ascending cholangitis, pancreatic necrosis, pseudocyst, hepatic abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care [1-8]. Additionally, there was no persistent hemodynamic instability or other complications. She had improvement with medical therapy. She was suspected to have a possible COVID-19 infection, but did not have markers of progressive COVID-19, and was appropriately treated for it [9,10]. The interventions performed, including labs, monitoring, imaging, gastroenterology consultation, and gradual advancement of diet, could have been performed in sequence after presentation without the inpatient level of care, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a female, who presented to the emergency department (ED) complaining of chest pain. Her medical history was remarkable for asthma. In the emergency department (ED), her blood pressure was 137/87 with a heart rate of 86 beats/minute. Her respiratory rate was 22/minute with a room air oxygen saturation of 99% (percent). An electrocardiogram showed sinus rhythm with nonspecific T wave abnormalities. Her serum troponin level was normal and remained normal when re-measured. Her brain (or B-type) natriuretic peptide (BNP) level was normal. Her D-dimer was elevated. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. The patient was treated with aspirin and bronchodilators and was admitted to the hospital. 

The inpatient hospital admission was not medically necessary.

This woman presented with chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Interstitial Lung Disease.
Treatment: Rituxan.
The insurer denied: Rituxan.
The denial is: Overturned.

The patient is a female with mixed connective tissue disease (MCTD) with moderate to severe interstitial lung disease (ILD). She has been treated with high dose steroids and Cellcept for one year without improvement on liver function test (LFTs) or recent high resolution computed tomography (HRCT). The subject under review is the medical necessity for Rituxan in this case.

Rituxan is medically necessary for this patient with MCTD associated ILD who is not responding to high dose steroids and Cellcept. There is myriad evidence supporting the use of Rituxan in connective tissue disease associated ILD.
Given the patient has MCTD and ILD and has not improved with steroids and Cellcept, it is very reasonable to try Rituxan given refractory disease. There was a study published in Drugs Context that concluded that "Rituxan (RTX) is a relevant therapeutic option for rheumatic disease-related ILD despite the existing uncertainties; ongoing trials are expected to clarify its use." A study in J Clin Med concluded that "lung function improved or stabilized in more than half of patients with CTD-ILD treated with RTX." Early treatment and combination with mycophenolate could reduce the risk of progression of ILD." Furthermore, a study in Lancet Respir Med found that "rituximab was not superior to cyclophosphamide to treat patients with CTD-ILD, although participants in both treatment groups had increased forced vital capacity (FVC) at 24 weeks, in addition to clinically important improvements in patient-reported quality of life. Rituximab was associated with fewer adverse events. Rituximab should be considered as a therapeutic alternative to cyclophosphamide in individuals with CTD-ILD requiring intravenous therapy."
The patient has MCTD and ILD. She is failing high dose steroids and Cellcept. There is data supporting the use of Rituxan in this case as outlined above, thus Rituxan is the best next step in management at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chalazion
Treatment: Tobradex Ointment
The insurer denied: Tobradex Ointment
The denial is: Overturned

The patient is a female with a chalazion of the right upper eyelid for whom coverage Tobradex ointment is the subject of review. Coverage was previously denied as not medically necessary as it was not identified that the patient had failed or could not use the preferred formulary alternative, generic tobramycin/dexamethasone suspension. Upon appeal, the provider states that the patient's chalazion is infected and she need an antibiotic as well as a steroid. The patient was allergic to neomycin in Polytrim. As the lesion is on the eyelid, an ointment is necessary rather than an eye drop. An exam confirms the patient having a chalazion of the right upper eyelid which had been treated with Polytrim and hot compresses. Due to allergy, treatment was changed to Tobradex ointment along with lid hygiene, hot compresses, and omega 3 fatty acids. The subject under review is the medical necessity for Tobradex ointment.

The health plan's determination is overturned.

The requested Tobradex ointment is medically necessary for this patient. While the preferred formulary alternative is a tobramycin/dexamethasone drop, the patient needs an ointment which can be applied to the right upper eyelid. It is not identified that such an antibiotic/steroid combination ophthalmic exists on the formulary alternative.
Chalazia are caused by inflammation and obstruction of sebaceous glands of the eyelids. While infection can cause the inflammation or obstruction that leads to a chalazion, the lesion itself is an inflammatory lesion for which conservative management is the initial strategy for chalazia. According to the Wills Eye Manual, this includes warm compresses and a short course of topical antibiotic/steroid ointment. As such an ointment is not identified on the formulary alternative, the medical necessity of Tobradex ointment is established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) chest pain associated with shortness of breath (SOB). The vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was unremarkable. Imaging studies included a computed tomography pulmonary angiogram (CTPA) which showed a left lower lobe (LLL) pulmonary artery branch pulmonary embolism (PE) with no evidence of right heart strain. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with a LLL pulmonary artery branch PE and was treated with anticoagulation. 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 c/o chest pain after a flight and was found to have a LLL pulmonary artery branch pulmonary embolism. The patient had no history of cancer, heart failure, or chronic lung disease, there was no hypotension, tachycardia, tachypnea, fever, altered mental status (AMS) or hypoxia. The pulmonary embolism severity index (PESI) score was consistent with class I, which is very low risk, with a 0-1.6 percent (%) 30-day mortality. The simplified (sPESI) was also indicative of low-risk. In addition, there was no respiratory distress, hemodynamic instability, recent bleeding, or serious comorbid conditions. Patients with a PESI score less than 65 are very low risk for 30-day mortality (0%), and those with a score less than 85 are low risk for 30-day mortality (1%); patients in these categories can be considered for outpatient management. This patient was monitored and received anticoagulation, which could have been provided safely at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

The patient is an adult and has anorexia nervosa, obsessive-compulsive disorder (OCD) and presented with poor oral intake. The patient was previously hospitalized for malnutrition and had electrolyte abnormalities and bradycardia. After discharge, the patient has continued to lose weight. The patient's father now has brought the patient back to the Emergency Room (ER). The patient was afebrile, and the vital signs were stable. A nasogastric tube was placed but then the parents did not want tube feedings. A plan was made to only use the tube if the patient did not eat enough at each meal. In spite of the nutrition plan the patient only reached a Body Mass Index (BMI) of 14. A transfer to an eating disorder program was advised but the patient was only amenable to a discharge to home. 

Clinical indications for admission for Anorexia Nervosa, Child or Adolescent 
(MCG (Milliman Care Guidelines) ORG:P-585) include having a subnormal BMI with the requirement for urgent refeeding as indicated by malnourishment due to rapid rate of weight loss. An additional indication is supervisory needs as indicated by strict staff supervision of meals, use of a nasogastric tube, and where the motivation to recover is poor with a refusal to eat appropriately. There also needs to be a concern that the condition will deteriorate without this level of care. 

This patient continued to lose weight and was refusing to eat after the previous discharge. The patient was closely monitored with the feedings and a nasogastric tube was inserted. The patient had poor motivation, only reached a BMI of 14.5, and refused to be discharged to an eating disorder program. This met the Milliman Care Guidelines (MCG) criteria for Anorexia Nervosa for an inpatient admission. The health care plan did not act reasonably and with sound medical judgment. An inpatient admission was medically necessary. The denial is overturned.

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 

The health plan acted reasonably. Based on clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department. The patient underwent an uneventful laparoscopic appendectomy and was discharged on the same day. There were no reported complications. Outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation.

The inpatient hospital stay was not medically necessary. Per clinical documentation, the patient presented to the emergency department with a three-day history of right lower quadrant abdominal pain and pelvic pain. There was associated nausea and vomiting. Vital signs were within normal limits. The white blood cell count was elevated to 14.0. A Computed Tomography scan was positive for early acute tip appendicitis. The patient underwent an uneventful laparoscopic appendectomy. The patient was cleared for discharge from a surgical standpoint and discharged on the same day. Admission may be necessary for patients with severe systemic illness (such as sepsis), poorly controlled comorbidities (such as Chronic Obstructive Pulmonary Disease, Chronic Heart Failure), or complications from the procedure (such as infection, bleeding) that require more than 24 hours of postoperative care. There were no immediate complications documented after the surgery. Peer-reviewed literature also indicates that outpatient laparoscopic appendectomy can successfully be performed in those with uncomplicated appendicitis. Suitable criteria for same-day discharge included that the patient was hemodynamic stable. The patient was tolerating liquids, and the pain was controlled on oral medications. Surgical documentation notes that the patient was uncomplicated. Therefore, the requested inpatient hospital stay was not medically necessary. Observation care would be more appropriate.

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 admission is not substantiated.