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

Diagnosis: Coronary Artery Disease 

Treatment: Inpatient Admission

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

This is a male patient with a history of hyperlipidemia, depression, alcohol use, and withdrawals. He presented to the Emergency Room (ER) in early 2019 with nausea and dizziness after drinking alcohol and using marijuana.  He had hypotension in the field, but was normotensive upon arrival to the ER. He was admitted for coronary artery disease and underwent a coronary angiogram. This showed non-obstructive coronary artery disease with a normal left ventricular ejection fraction. No coronary revascularization was indicated or performed. There were no procedural complications, and the patient was subsequently admitted overnight for further monitoring. He remained clinically and hemodynamically stable, and was subsequently discharged the next day to follow-up with a cardiologist.    

The patient underwent an uneventful cardiac catheterization procedure with no complications, remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted. Per MCG 22nd Guideline Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG), cardiac catheterization is an outpatient procedure. The patient did not meet inpatient admission criteria following the procedure. 

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

The patient presented after an initial episode of a generalized tonic-clonic seizure with fever. The patient was well until a few days prior to admission when rhinorrhea and fevers developed. The temperature went up to 103.5F and the patient was crying more than usual. The patient was seen by a primary doctor and had a negative influenza culture and a normal chest x-ray. However, the fevers continued and the patient had an episode of emesis. On the day of admission, the patient had a generalized tonic-clonic seizure of 5 minutes duration, including rolling eye movements and neck stiffness. The patient was sleepy for about 10-15 minutes after the event, and was brought to the emergency department for further evaluation. The patient had never had a seizure in the past, and there was no family history of seizures. Upon admission, the patient received intravenous fluids and ceftriaxone as well as seizure precautions with Ativan as needed. The patient continued to spike fevers up to 102.7 F.

The health plan's determination is overturned. The inpatient stay was medically necessary. This is a very young patient who presented after a generalized seizure associated with fever. Although the seizure had resolved, the patient continued to have fevers after presentation, with no obvious source. Various infections need to be considered for children with fever without a source, including urinary tract infection and occult bacteremia. In this patient, there was concern for possible sepsis or other serious infection, and intravenous fluids, parenteral antibiotics, and close monitoring were required in an inpatient setting while cultures were pending. The patient also developed wheezing during the admission and required every 3 hour albuterol treatments.

The decision-making at the time of admission for this patient was consistent with the patient's young age, the presence of a seizure in the context of fever with no obvious source, and the need for initiation of treatment with parenteral antibiotics while cultures were pending, with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with endometriosis and an 8 centimeter ovarian endometrioma and underwent a robotic hysterectomy with unilateral oophorectomy. The 57 minute procedure is reported to have been without complication, and the patient was discharged the following morning. The inpatient level of care is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The laparoscopic procedure is reported to have been performed as planned without intraoperative complication. Laparoscopic hysterectomy is generally considered an outpatient procedure. By the morning after surgery, the progress note reports the patient to have only mild pain, and be ambulating and voiding. The vitals were normal, and the patient tolerated a regular diet. No blood products or extra fluids were administered. There is no documentation in the multiple physician notes of any complications or unexpected events during the stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Need for Chronic Rehabilitation; chronic respiratory insufficiency, seizures 

Treatment: Inpatient Rehabilitation 

The insurer denied for Ongoing Inpatient Rehabilitation. The denial was reversed.

The patient is a female child who experienced hypoxic ischemic encephalopathy when born at less than 38 weeks of gestation. The labor was complicated by placental abruption. The child had asystole at birth and required cardiopulmonary resuscitation (CPR) in the delivery room. The child has multiple medical problems including reflux, aspiration pneumonia, seizures and chronic respiratory insufficiency. The child has sialorrhea and is maintained on glycopyrrolate. The child receives treatment with the VEST airway clearance device to help with airway clearance of secretions and required bilevel positive airway pressure (BIPAP) at night. The child also receives albuterol, baclofen, gabapentin, phenobarbital, phenytoin, and intranasal Versed. The child is feed by continuous jejunal tube feedings.
	
The child has had multiple hospitalizations in the past year and was initially admitted to a particular hospital in early 2019. Following this admission, the child required transfer back to another hospital for an acute hospitalization for another episode of pneumonia. The child was again admitted to the initial hospital for chronic rehabilitation in early 2019. There have been significant issues with arranging 24-hour home nursing services where the family lives, and this had prevented the transition of the child's daily care needs to be provided safely in the home. There had been attempts to arrange for transfer to a long term care facility, but there had been no bed availability. 

The patient is a medically complex child who has had multiple admissions for respiratory failure, pneumonia and seizures. The child's medical care needs are complex and require 24 hour home nursing care. When the staff at a particular hospital determined that the child was stable and they attempted to arrange for appropriate nursing care in the home, they were not able to arrange full services for daily care. Exhaustive efforts to find alternate care in a long term care facility were also unsuccessful, because of no bed availability in appropriate facilities to provide for the child's ongoing complex medical needs.

The insurer has determined that ongoing rehabilitation care will not to be covered. 
Based on the above, the medical necessity for the inpatient hospital services from is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with a past medical history of hyperlipidemia, hepatitis C, non-insulin dependent type 2 diabetes, opioid abuse on methadone, smoking, chronic kidney disease (CKD) (baseline creatinine 1.8-2), who was brought to the emergency room (ER) by Emergency Medical Services (EMS) after being found minimally responsive in his car with a blood sugar of 52. The patient has taken glipizide the day before, but not eaten anything the entire day prior to admission. 

In the ER, he was alert, awake, and responded to voice. He was oriented to time, place, and person. His initial management of hypoglycemia in the ER included 2 ampules of 50% dextrose, intravenous (IV) octreotide, and he was started on IV fluids (5% dextrose with normal saline [D5NS] at 75 cubic centimeters per hour [cc/hr.]). The patient was admitted for hypoglycemia. The patient's blood glucose was checked every 4 hours. The patient developed worsening anemia (hemoglobin [Hgb] 6.6). Repeat complete blood count (CBC) showed a hemoglobin of 5.8, and then another check showed a hemoglobin of 7.8. The patient's magnesium was repleted. His glipizide was discontinued. The patient was discharged. 
The health plan's determination is overturned.
This patient's hospitalization was medically necessary at an inpatient level of care.
The patient presented with symptomatic hypoglycemia (was found lethargic in his car), with blood sugars remaining under 70 during observation level/ER care. He required 50% dextrose (D50), and continuous fluids with dextrose. He also required monitoring of his blood glucose every four hours.
Hypoglycemia is a dangerous condition in diabetics and non-diabetics alike. According to the American Diabetic Association Standards of Medical Care in Diabetes:
"Patients with or without diabetes may experience hypoglycemia in the hospital setting. While hypoglycemia is associated with increased mortality, hypoglycemia may be a marker of underlying disease rather than the cause of increased mortality." 
Furthermore, the patient had CKD (baseline creatinine 2 according to his primary care physician [PCP]). Patient's with CKD are at an increased risk of hypoglycemia and require close monitoring and urgent treatment.
This patient was appropriate for an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
Inpatient admission was not medically necessary.

This male patient with history of CAD (coronary artery disease) had an atypical presentation of nausea, precordial pain and passing out. He was brought to ED where he had no evidence of acute ischemia, no arrhythmias, but due to his history of stent and his complaint of chest pressure was brought to cath lab. Uncomplicated radial artery catheterization revealed no significant CAD, including his previous stent being patient. Medical treatment was recommended, IVF was given, and he was observed in telemetry. After an uneventful night he was discharged the next morning. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. In this case, the patient's symptoms were atypical and unlikely to be representative of ACS (acute coronary syndrome). Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia ("abnormal EKG" was borderline). Cath showed no WMA (wall motion abnormality).  The physicians' treatment did not include medical therapy for ACS such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin). The patient had a radial cath without complications and he was discharged without any further treatment. 
  
The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. Catheterization revealed no significant disease. That procedure is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of active CAD. In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present, nor was there correlation of syncope to cardiac cause. No arrhythmias were noted, no valvular heart disease seen and no treatment given. There was no evidence that the patient's mild bradycardia was related to presentation, nor was it worked up or treated. 

Cardiac catheterization does not require inpatient level of care, especially if performed radially, no intervention, no change in treatment and no complications. All testing and therapy would be appropriate, safe and guidelines consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis 

Treatment: Inpatient Admission

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

This is a young female patient, non-sexually active who presented to the Emergency Department (ED) with right upper quadrant and flank pain the night prior, accompanied with nausea and one episode of vomiting. The patient reported that she had a UTI in the two weeks prior to this presentation (that encounter was treated with nitrofurantoin which she had completed six days of treatment). She has a history of multiple urinary tract infections (UTI) as a child. The patient received IV antibiotics on admission but was then switched to oral. Both abdominal ultrasounds were essentially normal (no renal calculus or hydronephrosis). Her urine analysis (UA) per report was normal. The patient was eating and drinking normally. The patient's exam by the admitting team was essentially unremarkable except for mild Costovertebral angle tenderness (CVAT) on the right. The patient was treated and discharged home. 

The culture from her prior UTI was reported in the notes to have grown E. Faecalis susceptible to Cipro (not this ED presentation) as at this encounter a culture was not obtained in the ED in the presence of a normal UA per report.  The culture obtained after "dirty" urine with abnormal UA on same day did not have any reported bacterial growth. There was no report of vomiting both in the ED or during hospital admission and she was taking medications orally. The documentation in the records does not meet the criteria for acute inpatient admission, Observation care would have been appropriate.

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

Diagnosis: Thyroglossal duct cyst
	
Treatment: Inpatient hospital admission

The insurer has denied coverage for Inpatient hospital admission. The denial was reversed.

The patient was a male who was a type 2 diabetic and was obese as documented by a BMI of 28.7. He underwent a two-hour 26-minute operative procedure for the removal of thyroglossal duct cyst. The anesthesia was completed. Subsequently, he had elevated blood glucose of 136 (70-99) on multiple occasions that required insulin. His pain score was 7/10.

The peer-reviewed literature notes that most but not all adults who undergo removal of thyroglossal duct cyst or discharged within 24 hours. The peer review literature notes that increased anesthesia time of greater than one hour 10 minutes would have greater post-operative complications. Obesity as documented by BMI has been determined to be associated with increased postoperative morbidity.

The health care plan did not act reasonably or with sound medical judgment or the best interest of the patient. The patient underwent a prolonged operative procedure, was obese, had hyperglycemia that required insulin, and several hours post-operatively he still had increased pain score of seven. The hospital admission was warranted for these conditions as there was a reasonable probability of postoperative complications.

The inpatient hospital services were necessary in the care of the patient as he had multiple conditions consisting of prolonged anesthesia time, obesity, and hyperglycemia that needed to be treated with insulin. All of the conditions were associated with increased post-operative complications. Because of these factors the hospital services including observation, insulin, and hydration were indicated.

The denial should be reversed as the patient had multiple medical factors which needed to be observed as they all were associated with increased post-operative morbidity and work care for the hospital.
  
Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: Hypoglossal nerve stimulator or Inspire upper airway stimulation system

The health plan should cover the hypoglossal nerve stimulator or Inspire upper airway stimulation system.

Otolaryngology's academy's recommendations, as well as the literature, support that this procedure is the treatment of choice for OSA (obstructive sleep apnea) as seen in this patient (1-4).  The patient has the appropriate diagnostic findings and has not tolerated CPAP.  The procedure is not experimental/investigational, and it is accepted standard of care. 

The hypoglossal nerve stimulator or Inspire upper airway stimulation system is likely to be more beneficial.

This patient has severe OSA, which is a potentially life-threatening disorder.  The patient requires therapy and has not tolerated CPAP.  At this point, hypoglossal nerve stimulation is the only therapy that can be beneficial besides a tracheostomy, which has severe life-altering consequences.  As such, hypoglossal nerve stimulation is the best option.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: Hypoglossal nerve stimulator or Inspire upper airway stimulation system

The health plan should cover the hypoglossal nerve stimulator or Inspire upper airway stimulation system.

The hypoglossal nerve stimulator or Inspire upper airway stimulation system is likely to be more beneficial.

All records were reviewed.  The patient is a male patient with a history of OSA.  AHI on sleep study was 21.3 with a BMI of 29.7.  The patient could not tolerate CPAP/BiPAP and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.  

There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with OSA who have failed, or cannot tolerate, CPAP therapy.  A prospective multi-center study documented a reduction of AHI out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported AHI reduction out to 18 months.  Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with OSA who meet FDA criteria for the procedure.  

In this particular case, the patient would meet FDA criteria for the device in terms of BMI, age, AHI and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy). The patient has had previous failed CPAP / BiPAP trials.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the health plan should cover the proposed treatment, as the requested procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rapid Atrial Fibrillation
 
Treatment: Inpatient Admission

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

This is a male patient with a past medical history notable for atrial fibrillation, hypertension, and hyperlipidemia. He presented to the ER in early 2019 with complaints of left flank pain, and was found to have used crystal meth 2 days prior. His blood pressure was 207/103. He was noted to be in atrial fibrillation with rapid ventricular response, with a rate of 115. He was admitted to the hospital. He ruled out for myocardial infarction, and had a normal nuclear stress test. He was subsequently discharged to follow-up with a cardiologist in 1-2 weeks.
The remainder of the workup was unremarkable, including unremarkable cardiac troponin. His clinical condition improved and he remained hemodynamically stable. Although the patient had new onset symptoms, criteria were not met for any other additional extenuating circumstances. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.

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

The patient is a female with medical history of gastroesophageal reflux disease (GERD), gastritis, and Helicobacter pylori.  She presented to the emergency department with severe mid-abdominal pain and recurrent, intractable nausea and vomiting.  She had an endoscopy showing rare positive Helicobacter pylori, and was subsequently on pantoprazole, which she had discontinued.  Vital signs were notable for tachycardia with pulse of 107 beats per minute.   Physical examination was notable for active emesis and diffuse abdominal tenderness, worse in the epigastrium.  Labs were notable for low potassium of 3.2 millimoles per liter (mmol/L).  She was treated with intravenous famotidine, metoclopramide, Haldol, morphine, potassium, and fluid boluses.  She was made nil per os.  She was admitted as an inpatient.  She was started on oral pantoprazole.  Her symptoms improved; she denied nausea, vomiting, and abdominal pain.  Her diet was advanced, and she tolerated a normal meal.  Hypokalemia was resolved with potassium of 3.5 mmol/L, and was attributed to vomiting.  She was discharged on oral pantoprazole.  At issue is coverage for the inpatient level of care. The health plan's determination of medical necessity is upheld in whole.  The inpatient level of care is not supported.  In this case, the patient presented with abdominal pain, nausea, and vomiting.  This was consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) with possible Helicobacter pylori infection.  However, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, acute pancreatitis, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction [1,2].  Endoscopy was not performed during the stay.  She had rapid improvement on proton pump inhibitor therapy and was on a normal diet the day after presentation.  Tachycardia resolved with hydration. Hypokalemia normalized within a day with appropriate treatment [3].  All of the measures that were undertaken, such as observation, monitoring, labs, intravenous fluid administration, pain medication, and transition to regular diet could have been performed without acute inpatient level of care.