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

Diagnosis: Obstructive sleep apnea
 
Treatment: Oral appliance therapy for sleep apnea

The insurer denied coverage for an oral appliance. The denial was reversed.

Patient presented for a recommendation on how to manage mild obstructive sleep apnea.  Oral appliance therapy was recommended, as patient was intolerant of the continuous positive airway pressure (CPAP) machine. Based on the results of the sleep study, the patient exhibits obstructive sleep apnea.  Oral appliance therapy is an accepted treatment modality in cases in which CPAP is unable to be tolerated or no longer effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Otitis media, conjunctivitis, Influenza A
 
Treatment: Inpatient admission, medications, monitoring
	
The insurer denied the inpatient admission. The denial was upheld.
This child had no significant previous medical history and presented to the Emergency Department (ED) with cough, fever, and ear infection for four days.  Per the patient's mother, the patient had been feeding less solid food than usual, was drinking as usual, but producing less wet diapers. The mother denied any vomiting. The patient and family were currently residing in a shelter. The patient was seen by the shelter's doctor who said the child had an ear infection, but no antibiotics were available at the time.  On arrival to the ED the child had a temperature of 100.2F. The heart rate was 146. The exam was significant for a disheveled appearance. There was no acute distress, and erythematous tympanic membranes (TMs) were noted bilaterally, as well as purulent eye discharge. The diagnoses at that time were "mild dehydration" and mucopurulent acute otitis media.  Labs were normal. The patient was found to be Influenza A positive. The patient received one normal saline bolus and ceftriaxone for conjunctivitis-otitis media syndrome. Per the admitting physician's note, the admission was based on the patient being febrile and tachycardic. The patient was tolerating oral intake, but was below the baseline with inadequate urine output. The plan was to admit the patient in the setting of oral intolerance. Temperature was 101.7F approximately 3 hours after arrival in ER.
This is a patient with some social issues with bilateral otitis media-conjunctivitis syndrome, Influenza A positive and mild dehydration secondary to illness causing inadequate oral intake. The patient received management in the ED consisting of ceftriaxone, intravenous fluids, and was started on oral Tamiflu. 
The inpatient admission was not medically necessary, and at most, the care received could have been at an observation level of care.  Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation with a Rapid Ventricular Response 

Treatment: Inpatient Admission

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

This is a female patient who presented to the ED in early 2019 and was found to be in atrial fibrillation with a rapid ventricular response. She ran out of medications but eloped without medications.  She had a history of hypertension, diabetes, asthma, schizophrenia, atrial fibrillation, and an implanted cardioverter defibrillation (ICD) for "arrhythmia." Patient stated that she was shocked three times that morning.  On arrival to the ED, vital signs included a blood pressure 160/106, a heart rate of 119, a respiratory rate of 30, a temperature of 98.4F, and an oxygen saturation of 96% on room air.  She was treated with Cardizem 25 mg intravenous, then diltiazem ER 360 mg orally.  Her ICD was interrogated and revealed that rapid atrial fibrillation was interpreted as ventricular tachycardia (VT) and her VT zone was reprogrammed to 250.  Laboratory test results revealed a white blood cell (WBC) count of 7.0, a hemoglobin of 14.3, a creatinine of 1.3, a brain natriuretic peptide (BNP) level of 430 and a troponin of 0.03, with a subsequent troponin was also 0.03.  A chest x-ray on this admission revealed cardiac enlargement and echocardiography revealed moderate to severe left atrial enlargement, moderate to severe left ventricular hypertrophy and a left ventricular systolic function of 55%.  She was discharged to home on Xarelto plus her home medications.

There is no evidence that this patient required an acute inpatient level of care to treat her atrial fibrillation with rapid ventricular response or to interrogate and reprogram her ICD.

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission

The proposed treatment, inpatient admission for detoxification and withdrawal management and other medical services, was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of unspecified anxiety and depressive disorder and ongoing substance use disorders with alcohol, opioid and stimulant class substances of abuse. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and the American Society of Addiction Medicine (ASAM) Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment, as noted above. There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services. The Inpatient admission or detoxification and withdrawal management and other medical services were therefore not medically necessary in this case scenario, as the health plan asserts, and the health plan's determination of medical necessity and decision is reasonable and clinically appropriate. And, NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the proposed inpatient level of care, as referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission
The proposed treatment, inpatient admission for detoxification and withdrawal management and other medical services, was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder and co-occurring depressive disorder with associated symptoms of anxiety. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and the American Society of Addiction Medicine (ASAM) Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment, as noted in the answer to question #2. There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services. The inpatient admission 1 for detoxification and withdrawal management and other medical services were therefore not medically necessary in this case scenario, as the health plan asserts. And, NY State LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gout
Treatment: Inpatient admission
The proposed inpatient admission is not deemed medically necessary.
This male patient with a medical history pertinent for diabetes mellitus, hyperlipidemia and gout presented to the ER for further evaluation/management of left foot and first toe pain and swelling. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air.  Examination was notable for erythema, edema and tenderness to palpation of the left first toe; the rest of examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with sepsis/bacteremia. Laboratory testing was without critical findings including no evidence of acute end organ damage.  
The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received treatment for gout flare with indomethacin, colchicine and steroids. He responded well to the prescribed therapies and was subsequently discharged in stable condition. 
There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient presented upon transfer to Cohen Children's Hospital in the afternoon. Ultrasound done at an outside hospital (transferring facility) showed appendicitis. Ultrasound was repeated at the receiving facility and showed similar findings to the outside ultrasound without evidence of appendiceal rupture. The patient was admitted to acute inpatient level of care @ 16:02. The patient underwent single incision appendectomy in the early evening. The operative report describes a straightforward procedure less than one hour in duration. The findings were acute non-perforated appendicitis. The patient was discharged home the following morning before 11:00. 

The care that the patient would have received at a lower level of care would have been identical to that which she received. The most appropriate level of care for treatment of non-perforated acute uncomplicated appendicitis is ambulatory. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in pediatric population is the procedure is considered outpatient with a short period observation in some cases. The care does not require acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: 64568 - Upper airway stimulator
The upper airway stimulator is medically necessary.

Medical necessity is generally defined as required to diagnose or treat an illness, injury, disease or its symptoms; in accordance with generally accepted standards of medical practice; clinically appropriate in terms of type, frequency, extent, site and duration; not primarily for the convenience of the patient, physician or other health care provider; and rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. 


For this patient, the proposed procedure is required to treat the sleep apnea, which is not controlled by more conservative measures.  It meets the standard of care and is not for the convenience of the patient.

The procedure and device are Food and Drug Administration (FDA) approved as referenced below and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with severe desaturations and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, there is strong support for the medical efficacy of the procedure. This is particularly evident with the withdrawal study by Woodson referenced below which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.  

The principal specialty in Otolaryngology (the American Academy of Otolaryngology- Head and Neck Surgery) has examined the scientific support for hypoglossal nerve stimulator in sleep apnea and concludes:

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.  

This patient has had proper evaluation and meets clinical criteria for this intervention.
Appeal type: Medical necessity
Decision: Overturned

This is the case of a patient who was found to have acute cholecystitis. The patient was evaluated in the emergency department and was admitted for acute cholecystitis. The patient was kept nothing by mouth (NPO) and given intravenous (IV) fluids and antibiotics and underwent laparoscopic cholecystectomy.

The health plan's determination is overturned. The inpatient stay was medically necessary. The standard of care for acute cholecystitis remains inpatient hospitalization, nothing by mouth, IV hydration, and, in most cases, antibiotics. Often times a cholecystectomy is performed during that hospitalization. Outpatient care is not appropriate for acute cholecystitis, which can progress to emphysematous cholecystitis, sepsis, gallbladder perforation and abscess, among other things.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with no other past medical history who presented to the emergency department with 2 days of abdominal pain and vomiting. Workup revealed an elevated white blood cell count of 19 and both an ultrasound and computed tomography (CT) scan imaging confirmed the diagnosis of acute cholecystitis with a stone in the gallbladder neck. 
The health plan's determination is upheld.  The patient underwent an uncomplicated laparoscopic cholecystectomy on 8/19/18 and was discharged home the same day. She had an isolated episode of hypotension that responded to fluids in the immediate postoperative period.  This is not an indication for inpatient admission and the care provided could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Drug and Alcohol Withdrawal
Treatment: Inpatient admission
The inpatient admission is not deemed medically necessary. 
This male patient presented to the ER for further evaluation/management of EtOH withdrawal. Intake vitals were afebrile, hemodynamically stable, with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with profound EtOH withdrawal/delirium tremens. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. 
The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received supportive care with IV fluids, electrolytes and prn benzodiazepines for withdrawal/agitation. He responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting the patient's safety or outcome. 
For these reasons, inpatient admission 06/01/2018 through 06/06/2018 is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal (Abdominal pain)
Treatment: Inpatient Hospital

Summary:  This patient presented to the Emergency Room (ER) with a complaint of worsening abdominal pain.  The patient reports that she was seen a week prior at another ER and was diagnosed with gastritis.  She has a past medical history of gastroesophageal reflux disease (GERD).  The patient was admitted and started on intravenous (IV) fluids.  Urinalysis was negative, and lipase and liver enzymes were normal.  Computed Tomography (CT) scan of the abdomen showed right stool burden.  She was seen by Gastroenterology, and they increased MiraLAX to 17gm three times daily.  Abdominal sonogram was recommended.  This was performed and reported as unremarkable.  Pelvic culture was positive for Gardnerella vaginalis for which Flagyl was started.  The patient was discharged home in a stable condition with instruction to follow up with gastroenterology as an outpatient.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary.  The denial was upheld.

The patient presented with abdominal pain. She was afebrile, and the vital signs were stable.  There was no abdominal rebound or guarding.  There was no leukocytosis.  CT scan revealed constipation.  A pelvic culture was positive for Gardnerella Vaginalis.  According to MCG, clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an outpatient basis and peritoneal signs.  The patient did not have these conditions.  She also did not have hemodynamic instability, intestinal obstruction, bacteremia, a severe electrolyte abnormality or an inability to maintain oral hydration.  This patient had abdominal pain and was diagnosed with constipation and a vaginal infection. The constipation could have been treated with a bowel regimen as an outpatient.  The vaginal infection could also have been treated with an antibiotic as an outpatient.  She did not meet MCG guidelines for admission for abdominal pain.  She could have been managed with observation status.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder (Ureteral stone)
Treatment: Inpatient Hospital

Summary: This patient with a past medical history of Crohn's disease presented to Emergency Room (ER) with complaints of right flank pain (7/10) and nausea. She had undergone a recent Computed Tomography (CT) scan which revealed a 6-7mm right ureteral stone with mild right hydroureteronephrosis. The patient was admitted with this condition, made nothing by mouth, she was taken to the Operation Room (OR) later that day for cystoscopy, right ureteroscopy with laser, stone basketing, and stent placement. The patient tolerated this procedure well. Post-operatively she was monitored overnight, remained medical stable, and she was discharged home the following day. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

Per Milliman Care Guidelines (MCG) Health Renal Colic & Kidney Stones RRG, this patient does not meet clinical indications for admission to inpatient care. These include: 1) Hemodynamic in stability, 2) Acute Renal Failure, 3) Solitary/ Transplant Kidney with Obstruction, 4) Severe Pain/ Vomiting acute in patient management, or 5) Urinary tract infection (UTI). Also per MCG Health Urologic Surgery or Procedure GRG, this patient is noted to have met the General Recovery Course Discharge parameter within 24 hours post procedure. As per the guideline, this procedure is normally designated for the ambulatory surgery setting. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer, past medical history of asthma, hypertension (HTN), high cholesterol, status post hydrocelectomy
 
Treatment: Cryoablation

The insurer denied the inpatient admission. The denial was upheld

This patient presented to the hospital for cryotherapy ablation of the prostate and prostate biopsy.  A Foley catheter was placed.  The patient was admitted to the hospital with diagnosis of acute cystitis and hematuria.  The patient was discharged home with Foley catheter in place and a leg bag.  

The insurer has denied coverage for the inpatient hospital admission as not medically necessary.  They noted the patient was admitted after an outpatient procedure and there were no problems after the procedure that required an inpatient admission.  They further noted that staying in the hospital for 23 hours after the procedure for observation is a part of the coverage for the authorized procedure.  

Per MCG Health (22nd Edition) Urologic Disease GRG, the patient fails to meet clinical indications for admission to inpatient care under subsection(s): 

-	Urologic infection requiring inpatient care
-	Gross hematuria requiring inpatient care
-	Acute urinary retention requiring inpatient care

Also, per MCG Health (22nd Edition) Urologic Surgery or Procedure GRG, the patient is noted to have met the General Recovery Course Discharge Parameter within 24 hours post procedure.  This procedure is normally designated for the ambulatory surgery settings, which may include a 23-hour period of observation after the surgery to ensure a safe discharge.

The medical necessity for inpatient admission is not substantiated.