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

Diagnosis: Diverticulitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld. 

The patient has a history of diverticulitis and an appendectomy and presented with abdominal pain, vomiting, and diarrhea. The patient was afebrile, and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. The renal function was normal. A computed tomography (CT) scan showed diverticulitis but without an abscess or perforation. Intravenous (IV) antibiotics were given, and the patient was then discharged on Cipro.

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, or a significant abnormality on an imaging study. This abnormality can be a fistula, obstruction, or free perforation. The patient did not have these conditions. The patient also did not require a drainage procedure, have bacteremia, severe dehydration, or an inability to maintain oral hydration after observation care.

This patient had diverticulitis that was not complicated by an abscess or perforation. The patient could have been treated with Intravenous (IV) antibiotics during observation care and then discharged on the Cipro. The patient did not meet MCG criteria for admission for Acute Diverticulitis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

The denial is upheld.

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a medical history of a recent Cesarean section five weeks prior. She presented to the emergency department with nausea, vomiting, and abdominal pain for a week; she had a similar episode of vomiting the prior week and a similar episode prior to that. Her vital signs were unremarkable. The physical examination was notable for a soft, nondistended abdomen with normal tenderness, and clean Cesarean section scar. A computed tomography scan of the abdomen and pelvis showed a distended gallbladder with prominent common bile duct and intrahepatic bile ductal dilation, hepatomegaly, and hepatic steatosis. An ultrasound showed gallbladder wall thickening of 4.8 millimeters (mm) and common bile duct dilation of 13.5 mm, with sludge and stones in the gallbladder, but no pericholecystic fluid.
She was treated with intravenous fluids, famotidine, acetaminophen, metoclopramide, and oral Maalox. She was made nil per os and started on cefoxitin, ceftriaxone, and metronidazole. Magnetic resonance cholangiopancreatography did not show choledocholithiasis. She denied nausea and vomiting; her pain had improved and she was passing flatus. Lab results showed an unremarkable complete blood count and basic metabolic panel. She was discharged on with a plan for surgery follow-up to arrange for cholecystectomy. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care is not medically necessary or supported by the provided information. The patient presented with symptoms and imaging consistent with cholecystitis, and elevated liver enzymes. However, she did not have imaging findings of choledocholithiasis, or evidence of ascending cholangitis, gallstone pancreatitis, 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. The patient did not have a cholecystectomy during the stay, and therefore did not experience postoperative complications such as pneumonia, sepsis, or bile leak which might require the inpatient level of care. The interventions performed, including labs, intravenous fluids, monitoring, imaging, specialist consultations, and antibiotic therapy, 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: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a history rheumatoid arthritis, and sickle cell trait, who presented with right upper quadrant pain. The review of systems was negative for additional symptoms.
The patient was afebrile. She was in moderate distress. 
The patient was admitted for abdominal pain. An ultrasound (US) of the abdomen showed dilation of the intrahepatic ducts, common bile ducts, pancreatic ducts, and echogenic lesion at the pancreatic head. Magnetic resonance cholangiopancreatography (MRCP) showed no changes in comparison to previous ones. The patient did not have stones or a tumor - there was unchanged dilation of the ducts. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was medically necessary.
Based on the documentation, the patient was admitted for abdominal pain, intolerance to by mouth (PO) intake and findings of biliary and pancreatic ductal dilation (common bile duct (CBD) of 1.0 cm). Inpatient admission was warranted for intravenous (IV) fluids hydration, expert consultation with gastroenterology/consideration of endoscopic retrograde cholangiopancreatography (ERCP) and repeat imaging with MRCP due to findings of pancreatic mass.
Patients with pain and associated dilated biliary and pancreatitis ducts warrant comprehensive evaluation for procedural intervention and clinical monitoring for improvement beyond an observation period. The patient also had a noted pancreatic lesion which carries a poor prognosis and warranted further imaging and consultation. The care could not have been safely rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ureter vesicular junction (UVJ) stone

Treatment: Inpatient admission.	

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is a patient who presented to the emergency department (ED) with complaints of lower back pain, nausea and urgency. Computed tomography revealed a 3 millimeter (mm) right distal ureter vesicular junction stone. In the ED, the patient was given intravenous (IV) fluids, various intravenous pain medications, and admitted to the urology service. The patient was kept nothing by mouth (NPO) for possible surgery, however the patient's symptoms improved, and passage of the stone was confirmed by imaging. The patient was discharged home the following day. 

The insurer has denied the inpatient admission as not medically necessary. They noted the patient's hemodynamic stability, and that the patient promptly passed the stone. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (27th) renal colic and kidney stones, the patient fails to meet clinical indications for admission to inpatient care (hemodynamic instability, bilateral obstruction, acute renal failure). In this case, the patient did not have or manifest hemodynamic instability, renal failure, mental status changes, or persistent vomiting and was not unresponsive to greater than or equal to 2 doses of an antibiotic. The patient had a small distal right ureteral stone which likely passed spontaneously due to hydration and expulsive therapy.

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: age-related cognitive decline, osteoarthritis, coronary artery disease, and diabetes.

Treatment: Personal Care Aide (PCA) Level 2: Live-In Per Diem- 1 day- 7 days per week- a total of 7 days per week.

The insurer denied coverage for Personal Care Aide (PCA) Level 2: Live-In Per Diem- 1 day- 7 days per week- a total of 7 days per week.

The denial is overturned.

 
This case involves an elderly female who lives alone in a 2-bedroom apartment. She has a supportive adult son. She is diagnosed with age-related cognitive decline, osteoarthritis, coronary artery disease, and diabetes. Her son sets up her medications weekly and the personal care aide (PCA) reminds her to take them daily. 

Her assessment did note a decline in some abilities and noted an additional 10 hours would be needed which allotted 49 hours per week of personal aide care. The request was for live in per diem 7 days per week. A letter was sent upholding the previous decision. The patient stated that she had fallen four times over the last month and suffered several bruises. She gets up frequently at night to use the bathroom due to taking diuretics. 

She is noted to need maximal assistance with dressing, bathing, toilet transfers, toileting, meal preparation, and medication management. She requires extensive assistance with personal hygiene, bed mobility, and ambulation. She requires limited assistance with eating. She is dependent on housekeeping. She is incontinent of both bladder and bowel.

This patient needs assistance for activities of daily living (ADLs). The lack of assistance has resulted in multiple falls. Thus, the increase in hours to live-in is supported as not being simply for safety but related to the need to perform ADLs. 

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 Personal Care Aide (PCA) Level 2: Live-In Per Diem- 1 day- 7 days per week- a total of 7 days per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, Nasal Congestion.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male child who presented to the emergency department (ED) with a two-day history of cough, nasal congestion, increasing difficulty breathing, and a one-day history of post-tussive emesis. He had a recent hospital admission for dyspnea secondary to rhinovirus/enterovirus infection. He has no history of asthma or reactive airway disease despite both parents having asthma but was noted to be belly breathing with oxygen saturation of 88-95 percent (%). He was given two nebulized albuterol treatments at home along with a dose of budesonide before coming to the ED. He had no fevers and was eating and drinking at baseline.
The examination was significant for mild respiratory distress, moist mucous membranes, congestion, mild tachypnea, mild subcostal retractions and abdominal muscle use, no wheezing or crackles, benign abdomen, no rashes, and non-focal neurologic exam. He was treated with three DuoNebs and a dose of dexamethasone, still with some abdominal breathing, and given another nebulized albuterol treatment. He was admitted for ongoing management. A viral respiratory panel was positive for rhinovirus/enterovirus.
Admission orders included routine vital signs, albuterol every three hours weaning as tolerated, continuous pulse oximetry, Orapred every twelve hours, asthma education, and Tylenol/Motrin as needed. He did well overnight with no need for supplemental oxygen, no further post-tussive emesis, and eating and drinking well. He was deemed stable for discharge home to complete a three-day course of prednisolone, continue albuterol every four to six hours, and follow up with his pediatrician in two to three days. At issue is the medical necessity of an inpatient admission.

No, a full hospital admission was not medically necessary for this child.
About half of all children experience an episode of wheezing in the first six years of life, often linked with a viral respiratory infection (e.g. respiratory syncytial virus, rhinovirus. Human metapneumovirus, influenza). Children may even experience recurrent episodes of wheezing as triggered by viral infection.
This young male child with a strong family history of asthma presented to the ED with a cough, congestion, and increased work of breathing. He had been in the hospital recently for difficulty breathing secondary to a rhinovirus/enterovirus infection. Testing remained positive. While it was not unreasonable to monitor him in the hospital for improvement in symptoms with aggressive bronchodilation, he was overall hemodynamically stable with no evidence of impending respiratory failure, no need for supplemental oxygen, and no difficulty eating and drinking. He did not require full hospital admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Intractable Axial Neck Pain.
Treatment:  Cervical Fusion.

The insurer denied coverage for cervical fusion. The denial is upheld.

According to the medical records, the patient is an adult female diagnosed with intractable axial neck pain. According to the provided records for review, there is no myelopathy or radiculopathy and no evidence of instability or compression. The request is for multilevel cervical (C) 4-C7 fusion (codes 22551 - arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2; 22552 x 2 - arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace; and 22845 - anterior instrumentation; 2 to 3 vertebral segments), which is under review.

"Cervical radiculopathy is a clinical condition resulting from compression of cervical nerve roots. The clinical manifestations of cervical radiculopathy are broad and may include pain, sensory deficits, motor deficits, diminished reflexes, or any combination of the above. Similarly, there are a variety different pathophysiologic processes which may result in dysfunction of the cervical nerve roots. In recent years, there has been considerable work performed in understanding the natural history of cervical radiculopathy as well as clarifying operative indications and outcomes following surgery." (Iyer, S., & Kim, H. J. 2016).

As there was no myelopathy, radiculopathy, or evidence of instability or compression, the requested service(s) is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for cervical fusion C4-C7 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: varicose veins
Treatment: Outpatient Surgery (CPT [current procedural terminology] 75822 x [times] 2, 37238 x 2)
The insurer denied Outpatient Surgery (CPT 75822 x 2, 37238 x 2).
The health plan's determination is overturned.

The patient is a woman with symptomatic varicose veins and venous insufficiency who has had multiple prior venous treatments.
The patient complained of discomfort in both legs, the left leg is worse. She also reported swelling, heaviness, fullness, cramps, weakness, fatigue, numbness, burning sensation, itchy, dark pigmentation, and knees pain. The patient has worn compression stockings daily.

The requested outpatient surgery (CPT 75822 x 2, 37238 x 2) is medically necessary.
The patient has symptomatic varicose veins and venous insufficiency with a complex history of multiple treatments. The patient was found to have stenosis of the bilateral iliac veins on venogram and intravascular ultrasound (IVUS).
The provider recommended stenting of the bilateral iliac veins. The requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid goiter
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with a history of a thyroid goiter (7 centimeter (cm)) in size. Because of the enlarged size (but benign disease on fine needle aspiration (FNA)), the patient underwent Left hemi-thyroidectomy. During the surgery, the Left recurrent laryngeal nerve was noted to be intact and stimulating normally. The American Society of Anesthesiologists (ASA) classification of the patient's anesthetic risk was a Class 3. A drain was placed at the time of surgery. Post operatively, pain was well controlled, and the patient was voiding, and ambulating well. 

The inpatient hospital admission was not medically necessary. The patient could have been admitted to observation status. There were no acute or chronic conditions (neck swelling, airway distress, hypocalcemia) that necessitated a full admission. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult who as per the triage note presented to the emergency room (ER) with abdominal pain and bloating for 1 day. The patient denied nausea or vomiting. The patient was afebrile with stable vital signs. The patient had not had a bowel movement in 2 days. The patient denied fever, chills, nausea or vomiting. The examination revealed the abdomen to be soft non-tender and non-distended. On reassessment the right lower quadrant (RLQ) was tender to palpation. A computed tomography (CT) scan was suggestive of acute cholecystitis. The patient was admitted to surgery. The patient was made nothing by mouth (NPO) and intravenous (IV) antibiotics were ordered. White blood cell count (WBC) was 9.43.

The history and physical (H & P) indicated 1 day of diffuse abdominal pain. CT with IV contrast was equivocal for acute cholecystitis. There was a suggestion of wall thickening and no visible gallstone on CT. A right upper quadrant (RUQ) sonogram was done which revealed a 2.2 centimeter (cm) stone at the neck. The common bile duct (CBD) was 5 millimeters (mm). The patient did endorse that this has happened before but this episode was worse. 

A progress note indicated the pain was well controlled with the current regimen. The patient denied nausea, vomiting, fever, and chills. Liver function tests (LFT's) were normal. The plan was possible operating room (OR) that day.  The progress note indicated the patient denied nausea or vomiting. The pain was well controlled and the patient was afebrile. WBC was 4.54. The plan was for a laparoscopic cholecystectomy.

The patient was taken to the operating room for laparoscopic cholecystectomy. Surgery was uneventful. The patient was discharged from the post anesthesia care unit (PACU). The postoperative note indicated the patient was doing well. The plan was for a regular diet.
The progress note indicated the patient reported some pain after lots of ambulation. The patient was otherwise doing well and the plan was for discharge to home.

The acute inpatient admission was not justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting. The patient had an uneventful laparoscopic cholecystectomy for cholelithiasis. The patient did not have a significantly elevated WBC and there was no fever. The patient did not have markedly abnormal LFTs. The patient presented and was not taken to the operating room (OR) until 3 days later. There was no reason for the surgery not to have been done sooner if this was truly an emergency. The patient most likely had biliary colic and did not merit an admission for acute cholecystitis in this case. This should have been done in an ambulatory/observation setting.

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stone

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is a patient with a history of benign intracranial hypertension (BIH) who presented to emergency department (ED) after being seen the prior day and diagnosed with a 5 millimeter (mm) left kidney stone with mild left hydronephrosis. Urinalysis (UA) was negative for a urinary tract infection (UTI) at that time. The patient was given intravenous (IV) fluids and IV Toradol, and admitted to inpatient. Urology evaluated the patient. It was felt that there was no need for acute genitourinary (GU) intervention as the patient was comfortable without flank pain at the time of their evaluation. The patient was admitted, given IV fluids, Flomax, and IV Toradol. The patient improved and was discharged with an outpatient follow up with urology.

The insurer has denied the hospital admission as not medically necessary. They noted the lack of complications and medical co-morbidity. The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guidelines (MCG) Health (27th) Renal Colic + Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care. These include UTI, hemodynamic instability, acute renal failure, and bilateral obstructions. 

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 full hospital admission is not substantiated.