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

Diagnosis: Suicidal Ideation

Treatment: Inpatient Hospitalization

The insurer denied the Inpatient Hospitalization. The denial was reversed. 

This is a male patient who was brought to the emergency department by emergency medical service after calling a friend expressing that he no longer wanted to live.  He had a history of alcohol abuse and depression with psychotic features, insomnia, traumatic brain injury with poor impulse control, hypertension, and a seizure disorder. He reported depressive symptoms. The patient reported that he had been drinking beer and had an alcohol level on admission of 188. He further added that he presented to another hospital two weeks earlier with similar symptoms; he was sent home from that hospital.  On psychiatric evaluation he reported active suicidal thoughts without a plan.  It was determined that he was a suicidal risk and arrangements were made for psychiatric hospitalization to another facility. Due to a winter storm the transfer did not occur.  A telepsychiatry evaluation was performed during his hospital admission, deeming him safe to continue care on an outpatient basis.

The patient had a history of depression and acute suicidal ideation.  Although he did not articulate a plan he had a history of traumatic brain injury (TBI) with high impulsivity.  Professionals evaluating him at the time of admission assessed his risk of suicide to be high and they made arrangements for acute psychiatric hospitalization (which could not be accomplished due to a winter storm).  They could not know that he was likely to improve within 24 hours to the point that he could be safely discharged.
This finding is consistent with the general standards of psychiatric care as well as the American Psychiatric Association (APA) Guidelines for the Treatment of Patients with Major Depressive Disorder and the APA Guidelines for the Treatment of Patients with Substance Use Disorder.  

The carrier's denial of coverage for inpatient admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female under consideration for bariatric surgery. At the time of evaluation in 2018 she was 67.7 inches tall and weighed 285.2 lbs. This corresponds to a body mass index (BMI) of 43.8 kilograms per square meter (kg/m2). She has comorbid health conditions of arthritis. The patient has attempted weight loss with dietary efforts as are detailed in the evaluation in 2019. Unfortunately, she has not been successful with significant sustained weight loss. 

The health plan's determination is overturned, in whole.

Given this patient's diagnosis, her current health condition and my medical judgment, the proposed sleeve gastrectomy procedure that was performed in 2019 was medically necessary for this patient and was consistent with generally accepted guidelines established by The National Institutes of Health and The American Society for Metabolic and Bariatric Surgery. This patient had an initial BMI in excess of 40 kg/m2. She has successfully completed a multidisciplinary bariatric evaluation as detailed above.
Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is not cosmetic or experimental, is proven to be more medically effective than any standard nonsurgical care and treatment and is not for the convenience of the patient or physician. The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.
LSG (laparoscopic sleeve gastrectomy), was medically necessary for this patient based on the current standard of care and evidence-based literature for the following reasons:
i)	The patient meets the widely accepted National Institute of Health (NIH) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG procedure (BMI of > 40 kg/m2, comorbid conditions arthritis, failed nonsurgical efforts to promote sustained weight loss.
ii)	The patient has been evaluated by a multidisciplinary bariatric program. There is documentation of consultation with a dietician, a mental health provider, and her surgeon.
iii)	The LSG procedure is not investigational or experimental. It has garnered the support of ASMBS guidelines and has proven efficacy and >5-year weight loss comparable to other bariatric procedures.
The proposed sleeve gastrectomy that was performed was medically necessary and was consistent with standards established by the National Institutes of Health and The American Society for Metabolic and Bariatric Surgery.
Appeal type: Medical necessity
Decision: Upheld

This patient is under consideration for revisional bariatric surgery. The records indicate that the patient underwent gastric sleeve surgery in 2012. Moderate initial weight loss was realized. Documentation notes an endoscopy was performed on 2/23/19 that showed a retained fundus with an otherwise normal sleeve caliber. The records do not include objective confirmation of these endoscopic findings that were identified by the treating surgical group. There are currently no universally accepted guidelines for the management of refractory morbid obesity following prior gastric restrictive procedures. There needs to be objective confirmation of a significant anatomic complication of the existing sleeve. The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease, shortness of breath
 
Treatment: Inpatient admission, diagnostic testing, monitoring, medication

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

The patient is a male with history of chronic obstructive pulmonary disease (COPD), hypertension, diabetes mellitus, end stage renal disease (ESRD) on dialysis who presented with complaints of shortness of breath and chest tightness of two days duration.  The patient had been seen the previous day for the same symptoms and was treated and discharged on oral (PO) steroids, but the patient had not filled his prescription.  The patient also complained of chills and palpitations.  Vital signs at presentation were: temperature 98.4F, respiratory rate 18, blood pressure 185/87 and heart rate 88.  Oxygen (O2) saturations were 99%. Pro Brain Natriuretic Peptide (BNP) was 4792; Troponin was 0.058.  EKG: T wave inversion inferolateral leads.  Pro Cal was 0.09. Chest x-ray showed no active disease. The patient was treated with intravenous (IV) steroids, bronchodilators, and IV Lasix.  Echocardiogram revealed an ejection fraction of 70%.  There was no pericardial effusion.  

This patient remained stable after admission. He was afebrile, hemodynamically stable and not hypoxic.  There was no evidence of pneumonia or heart failure on chest x-ray.  The patient could have been placed in Observation status and diagnostic testing and treatment initiated.  He responded to treatment and was stable the next day to be discharged home on oral medications.  Troponins were mildly elevated, likely from ESRD.  EKG remained unchanged.  The patient did not complain of any chest pain.  There were no signs of acute coronary syndrome (ACS).

The patient did not need acute hospitalization. He likely had mild chronic obstructive pulmonary disease with some fluid overload which responded to treatment in the ED.  
The patient was stable for discharge after a brief period of observation, on oral medications with close follow-up in an outpatient setting.  

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

Diagnosis: Abdominal pain 
Treatment: Inpatient admission
The inpatient admission was not medically necessary. The treatment as rendered was medically appropriate, but the care was not rendered at a medically necessary level.
The patient is a female. She had presented to the emergency department with the complaints of abdominal pain. The patient had actually been pending an exploratory laparoscopy with lysis of adhesion surgery. The patient has had this pain chronically. The patient noted an increasing frequency. The patient was taking oxycodone for pain. The patient was still passing flatus and noted constipation.  The patient did not have a fever. 

The patient's presenting vital signs were normal. A CT scan showed an abnormal area with a possible underlying mass or lesion but no obstruction and possible changes consistent with colitis. The hemoglobin was 8.6 and pyuria and hematuria was noted. There was a history of laparoscopic cholecystectomy and prior appendectomy.  The patient was admitted and she received supportive care including IV fluids. The patient underwent a colonoscopy showing a fibrotic anastomosis from a colon anastomosis with a small ulceration noted. The patient's diet had been advanced and the patient was discharged home. 

The plan's denial was correct. The patient did not require a full acute admission. The patient had an exacerbation of a chronic condition. 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 an infection; yet she 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 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Torsion, Urinary Tract Infection 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a young female patient who presented to the emergency room in mid-2019 with a chief complaint of severe abdominal pain. A pelvic ultrasound was performed and revealed an enlarged heterogeneous left ovary containing a cyst which was concerning for ovarian torsion. She underwent a laparoscopic left salpingo-oophorectomy and a dilatation and curettage. While in the hospital the patient was treated with intravenous fluids, antibiotics, and pain medication. The patient tolerated the procedure well with no post-operative complications. The patient was medically stabilized and then discharged home.

This patient underwent a laparoscopy. A laparoscopy is an ambulatory procedure.
According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for:
Older patients (> 65)
Conversion to abdominal procedures
Surgical complications
Comorbidities

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain
Treatment: Synvisc injection
The Synvisc injection is not medically necessary.

The patient is a female with bilateral knee pain for years. She had been diagnosed with osteoarthritis. She had received "gel injections," which had given her approximately eight months of relief. Her last injection was provided in at the beginning of last year. Her pains were worse with walking. She had tried PT (physical therapy) but it made her pain worse. She had associated swelling and difficulty with bending. 

The physical examination was significant for no specific finding. Imaging was unremarkable. Her physician diagnosed osteoarthritis and recommended "gel injections."

The scientific literature had previously recommended viscosupplementation for the treatment of osteoarthritis 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 AAOS cites the following:

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 (hyaluronic acid) 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: Knee arthritis
Treatment: Gel-One (Hyaluronan) injection 
The Gel-One (Hyaluronan) injection is not medically necessary.

The patient is a man with mild to moderate osteoarthritis (OA) to his left knee. He has swelling and pain due to cartilage loss. The physical examination was significant for decreased motion, tenderness and effusion. Imaging showed moderate to mild osteoarthritis. His physician reported, "no real options other than Viscosupplementation." 

Injections of hyaluronate were recommended. 

There is debate on the effectiveness of the injections. It is difficult to assess overall treatment.  The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis 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 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: Localized skin and soft tissue infection
 
Treatment: Inpatient admission, medications, monitoring

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

The patient has a past medical history significant for polysubstance abuse and deep vein thrombosis x 2 who returned to the Emergency Department with worsening lower extremity swelling. Vital signs on presentation included a temperature of 98.3F, a blood pressure of 136/89, a pulse of 66, a respiratory rate of 16, and an oxygen saturation level of 98% on room air. The patient was admitted for lower extremity swelling and erythema. He was started on antibiotics (clindamycin) and methadone. The patient remained afebrile, hemodynamically stable, and was discharged on a course of oral antibiotics to follow-up as an outpatient.

According to documentation, the patient presented with lower extremity swelling consistent with a cellulitis. Otherwise, the patient was afebrile and hemodynamically stable with unremarkable laboratory results, including a normal WBC count (10.5). The patient had a localized skin and soft tissue infection. No surgical intervention was required and there was no evidence of a systemic infection. Moreover, the patient was capable of tolerating oral antibiotics and there was no documented failure of outpatient therapy.

The prior determination of the denial of hospital admission has been upheld. Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Choledocholithiasis
Treatment:  Inpatient stay 

Summary:
The patient is a male with two-week history of epigastric pain associated with productive cough.  The patient has a past history significant for hepatitis B status post cholecystectomy.  Vital signs were stable without any temperature and a normal heart rate.  Abdominal exam was identified as being soft with epigastric tenderness and no guarding, rebound, or tenderness.  CT scan revealed choledocholithiasis. 

There was no hemodynamic instability, fever, a normal heart rated, and his white count was normal. ERCP was performed in a timely fashion without any untoward events.  The proposed acute inpatient treatment of this particular patient was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids and thickened endometrium
 
Treatment: Inpatient admission, surgery, post-operative monitoring

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

The patient is a woman who was admitted for surgery due to uterine fibroids and thickened endometrium.  She underwent a robotic assisted Total Laparoscopic Hysterectomy, Bilateral Salpingo-Oophorectomy, and Vaginal Laceration Repair; estimated blood loss (EBL) was 300cc.  A post-operative note documented that the patient was stable with no complaints.  The patient was discharged home the next day. 

Robotic-assisted hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or if the severity of the pain is such that admission is necessary.
According to MCG, Laparoscopic Hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure.  Inpatient stay may be needed for: Surgical complications (bladder ureter or bowel injury or hemorrhage), Conversion to abdominal hysterectomy,
Complex surgery (staging of endometrial cancer), Wound complications, Co-morbidities.

This patient did not have any of these criteria.  Her procedure was uncomplicated.  There was a small vaginal laceration that was repaired.  Postoperatively, the patient was stable.
Nothing in the progress notes suggested any serious problem that warranted admission.  Please note that a robotic-assisted laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anal Fistula
Treatment:  Inpatient Stay

Summary:
The patient is a  male who presented with rectal pain for four days. He complained of fever and no chill, nausea or vomiting. His past history was significant for anal fistula. In this patient's case, there was no sign of any systemic infection. Having a past history of anal fistula does not change the medical or surgical management of this patient's acute, active anal infection. This could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcoholic Hepatitis, Alcohol-related pancreatitis
Treatment: Inpatient stay 

Summary:
The Inpatient admission was not medically necessary. The patient is a female who had a history of opioid and alcohol dependence. The patient presented with signs of withdrawal and fevers, tachycardia, a lipase of 76, and hypokalemia.

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 abdominal pain; yet she did not show evidence in 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. There were no signs of liver failure or synthetic liver dysfunction. There were no CT signs of pancreatitis, and there was no significant elevation of lipase.  As such, the care could have been rendered at a lower level.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the hospital with a chief complaint of lesions on his face, thrush, fevers, and enlarged glands in the neck. The patient had been seen by an oral surgeon and treated with steroids. The symptoms developed after dental work. Recently, the tongue lesions had worsened and he had been seen again by an ear nose and throat surgeon who treated him with antibiotics and steroids. The patient reported recent improvement but progressively worsening weight loss, sweats, and chills. Two days prior to presentation, the patient also became weak and was unable to walk. The patient denied drug abuse. Vital signs showed blood pressure 119/67, heart rate 93, respiratory rate 18, oxygen saturation 96%, and temperature 99.0 Fahrenheit. On physical examination, the patient had multiple ulcers in the oropharynx and decreased moisture. The patient was treated with IV antibiotics with improvement of the oral lesions and was discharged with oral antibiotics. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient admission was not medically necessary. The patient primarily received an outpatient evaluation and treatment plan. The administration of the IV antibiotics could also have been performed at a lower level of care safely and effectively. In addition, the imaging tests that the patient underwent could also have safely and effectively been performed at a lower level of care. The patient was hemodynamically stable and had no evidence of airway compromise or suspected need for mechanical ventilation.