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

Diagnosis: Epigastric chest pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with a history of hyperlipidemia and hypothyroidism. She presented to the hospital with epigastric chest pain. Her white blood cell (WBC) count was normal. Her vital signs were stable. Her liver function tests (LFTs) were mildly elevated. Her ultrasound (US) showed cholecystitis. Gastroenterology (GI) was consulted, magnetic resonance cholangiopancreatogram (MRCP) showed normal common bile duct (CBD). She underwent laparoscopic cholecystectomy and was discharged.

The requested health service is not medically necessary.

The documentation shows there is no indication per the Milliman Care Guidelines (MCG) criteria attached that this patient met inpatient criteria. The patient was hemodynamically stable, had no major intra-abdominal sepsis, she did not require management for her chronic medical conditions, and she underwent uneventful laparoscopic cholecystectomy. Her white blood cell count was normal, and her labs did not demonstrate any other major abnormality. Per the Milliman Care Guidelines criteria, this does not meet medical necessity for inpatient admission. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stones. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient has a past medical history kidney stones, lactose intolerance, colitis, and intellectual disability. The patient was recently hospitalized with colitis. The patient presented to the emergency department (ED) complaining of abdominal and right flank pain. The patient's urinalysis revealed hematuria.  A computed tomography (CT) scan showed 3.4 millimeter (mm) stones in the distal right ureter, and a questionable bladder stone.  The patient was admitted, given intravenous (IV) fluids, IV Zosyn, and taken to the operating room the following day for a cystoscopy, right ureteroscopy (URS), laser stone ablation, and stent placement. The patient tolerated procedure well with no complications and was stable for discharge the next day. 

The insurer has denied coverage for inpatient hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health Renal Colic and Kidney Stones, the patient fails to meet guidelines for admission to inpatient care. The patient had no urinary tract infection (UTI), was hemodynamically stable, and had no acute renal failure. The patient did not meet MCG Urologic Surgery or Procedure guideline for inpatient admission given the patient was stable for discharge within 24 hours post-procedure (2). 

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

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

This is a male patient with no past medical history (PMH) who was admitted with complaints of (c/o) right leg pain and erythema after cutting himself and completing a course doxycycline and recently starting clindamycin. His vital signs were unremarkable. The physical exam was notable for right lower extremity (RLE) edema and erythema with medical fluctuance, warm and tender to palpation (TTP). Lab work was unremarkable. Imaging studies, a right lower extremity (RLE) ultrasound (US) showed a complex fluid collection and possible abscess versus hematoma and no deep vein thrombosis (DVT). The patient was diagnosed with RLE cellulitis and an abscess and treated with intravenous (IV) antibiotics and underwent a RLE irrigation, debridement, and incision and drainage (I&D), which demonstrated a hematoma without purulence. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with c/o right leg pain and erythema after cutting himself and completing a course doxycycline and recently starting clindamycin. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with IV antibiotics and an I&D, and this could have been safely provided at a lower level of care. The patient's I&D did not demonstrate an abscess, but a hematoma without purulence. A lower level of care can provide for the management of mild cellulitis infections because it allows frequent reevaluation to assess response to therapy while avoiding inpatient admission. Overall, this patient could have been safely treated at a lower level of care. The patient did not have an immunocompromised state, infection over a prosthesis or implanted device, or orbital cellulitis.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with asthma who presented with 2-3 weeks of increasing dyspnea. He was recently hospitalized for similar symptoms after being diagnosed with COVID but left against medical advice (AMA).
In the emergency department (ED), temperature was 37.0oC, blood pressure (BP) 126/91, heart rate (HR) 94, respiratory rate (RR) 23, and pulse oximetry 92% room air (RA). On exam, he was not in distress, heart was regular, diffuse wheeze, and alert and oriented. 

The inpatient admission was not medically necessary. The patient presented with shortness of breath (SOB) and was diagnosed with an acute asthma exacerbation and possible pneumonia. He was not severely ill at presentation with no encephalopathy, hemodynamic instability, respiratory distress or marked gas exchange abnormality, acute kidney injury or significant electrolyte abnormality. He was not at high risk of worsening from pneumonia or an asthma standpoint. He had a productive cough the following day but no report of shortness of breath (SOB), and he then left against medical advice (AMA). As he was not severely ill at presentation and was unlikely to become so, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: subdural hematoma 
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This patient is a male who presented after a syncopal episode and a fall. He was evaluated with computed tomography (CT) scan that showed a thin right posterior subdural hematoma and a right facial bone fracture. He was transferred for further evaluation and follow up imaging. The Glasgow Coma Score was 15 at the time of presentation. A Neurosurgical consultation was obtained with recommendation for neurological checks every 4 hours, oral Keppra, and repeat CT scan of the head.

The inpatient hospital admission was not medically necessary. This patient presented to the hospital as a transfer patient following a head injury that resulted from a syncopal event with a fall. While the submitted records do not include the actual medical record from the original facility, the submitted material does support that he was clinically and hemodynamically stable at the time of arrival. He was determined by the neurosurgical consultant to not require operative intervention. He was able to tolerate oral intake and medications. The submitted material indicates that the follow up computed tomography (CT) scan of the head showed no new findings.
Per the Milliman Care Guidelines (MCG): Admission is indicated for head injury and one or more of the following: Hemodynamic instability, altered mental status that is severe or persistent, Post-resuscitation or presenting Glasgow coma score of < 13, worsening neurologic function, new signs or symptoms, new focal signs on neurologic examination, evidence of increased intracranial pressure, new intracranial pathology on imaging, cerebrospinal fluid (CSF) leak, recurrent seizures, significant respiratory abnormalities secondary to the brain injury, increased intracranial pressure or cerebral edema monitoring. In this case, none of these neurological criteria were present to warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: neck lipoma
treatment: surgical services
The insurer denied Outpatient Hospital Department Site of Care 
The health plan's determination is upheld. 

This patient had a left neck lipoma. He was treated with excision of the mass which was located in the subfascial plane. Adjacent tissue transfer was used to close the wound.

The Outpatient Hospital Department Site of Care was not medically necessary for this patient. The patient could have been cared for in an ambulatory surgery center level of care. In this case, the approach for surgery was not complex and operative time was short. The patient was not identified as high risk preoperatively. No drug related risks were documented preoperatively. Discontinuation of critical medications was not required for completion of the procedure. Finally, there is no documentation of an inadequate outpatient situation. The patient could have been safely cared for in an ambulatory surgery level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain and Vaginal Pain. 
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is overturned. 

The patient is an adult female. She was admitted to the hospital emergency room (ER) with abdominopelvic pain, vaginal bleeding, fever, and chills following a termination of pregnancy and insertion of intrauterine device (IUD) two days prior. She was admitted with a diagnosis of sepsis associated with an acute pelvic infection. A computed tomography (CT) scan of the pelvis revealed the intrauterine device in the right lower uterine segment of the endometrial cavity, in an abnormal position. Intravenous fluids, intravenous antibiotics, and intravenous morphine were administered. A dilation and evacuation (D&E) with intrauterine device removal was subsequently performed. The patient was admitted as an inpatient and continued on intravenous antibiotics. She was discharged on day #4. 

The inpatient admission was medically necessary. 

The medical records and medical literature were thoroughly reviewed. The patient had a diagnosis of a septic abortion. This is an extremely serious and potentially life-threatening condition with a fatality rate of 0.4 to 0.6 per 100,000 first-trimester pregnancy losses. Elevated temperature, leukocytosis, lower abdominal pain, cervical motion tenderness, and a purulent vaginal discharge are all signs of septic abortion. Infection can spread from the endometrium through the myometrium and eventually affect the parametrium and peritoneum. The cause is most often polymicrobial, with Escherichia coli and other aerobic gram-negative rods involved. Group B streptococci, anaerobic streptococci, Bacteroides, and Clostridium perfringens may also be implicated. Shock can occur from the release of endotoxins. Patients presenting with signs and symptoms of septic abortion should be stabilized with fluids and blood products as needed. 
Blood and cervical cultures should be obtained, followed by the administration of broad-spectrum intravenous antibiotics. Choice of antibiotics is typically the same as for pelvic inflammatory disease. Evacuation of the uterus should be performed with extra care given the increased risk of perforation in an infected gravid uterus. All of these clinical maneuvers were performed. Inpatient admission was required as a standard of care. Per the standard of care, the patient was managed as an inpatient. When she was determined to be stable and afebrile, she was discharged. Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pneumonia.
treatment:  Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male who came to Emergency Room (ER) with complaint of fevers, chills, shortness of breath, and cough for 5 days and diarrhea of one day. In the emergency room (ER), his initial vital signs were Temperature 104; heart rate (HR) -98; blood pressure (BP) 148/66; respiratory rate (RR) 32; and pulse oximetry 98% The physical examination was remarkable for decrease breath sound and rhonchi. The patient was ill appearing but could speak full sentences. On labs, the white blood cell count (WBC) was 19.7, HCT (hematocrit) 40.9. Na (sodium) 136; blood urea nitrogen (BUN) and Cr (creatinine)15/1.1, and Glucose 157. A chest x-ray (CXR) reported linearly oriented left lower lobe airspace opacity. He was admitted to medicine with acute bacterial pneumonia.

The inpatient hospital admission was not medically necessary. The patient was presented to the emergency room (ER) with fever, shortness of breath and cough. He had temp of 104 that came down to 98 with Tylenol and intravenous (IV) antibiotics in ER. He was not hypoxic while in the ER or on the floor and was not hemodynamically unstable. He did not require high oxygen, positive airway pressure (PAP), or a ventilator.
His chest x-ray (CXR) reported airspace opacity in the left lower lobe - suggestive of community acquired pneumonia possibly human immunodeficiency virus (HIV) related. He is complaint with HIV medication. He did not require respiratory isolation. He did not require any surgical intervention while in hospital.
His Pneumonia Severity Index (PSI) score is 76 points, which is Low risk. He could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain.

Treatment: Hyaluronan or Derivative, Orthovisc, Forinta-Articular Injection, per dose.

The insurer denied coverage for Hyaluronan or Derivative, Orthovisc, Forinta-Articular Injection, per dose.

The denial is upheld.
 
This is an adult female with right knee pain. She also reported back pain. She was also diagnosed with a meniscal tear. She had received treatments of epidural steroid injections (ESI) and cortisone injections to the right knee. Her physician has recommended viscosupplementation. 
A review of the Clinical Practice Guidelines (CPG) by the American Academy of Orthopedic Surgeons (AAOS) cites:
The 2013 osteoarthritis (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 3 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".
This topic was reviewed again in 2021. Additional studies were reviewed with the opinion:
No change to this Guideline. 
Additional references and expert opinion do not support benefit. (see below).  A meta analysis was completed of multiple references. This is a high level evidence based criteria which does not support use. 
Hyaluronan or Derivative, Orthovisc, Forinta-Articular Injection, per dose is not considered medically necessary for this patient.
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 Hyaluronan or Derivative, Orthovisc, Forinta-Articular Injection, per dose is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Class I malocclusion.
Treatment: braces.
The insurer denied braces.
The health plan's determination is overturned. 

The patient in question is a young male with a Class I malocclusion. He has severe crowding. He has a 7-millimeter (mm) overjet and 6 mm overbite. He is treatment planned for 24-30 months of orthodontics (braces) with extraction of the four first premolars to correct his malocclusion. 

Braces are medically necessary for this patient. This patient has an excessive overjet despite his Class I occlusion. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has. Braces to correct his excessive overjet will reduce the risk of trauma and improve his quality of life. For these reasons, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces and Monthly Visits.
The insurer denied Braces and Monthly Visits.
The determination is upheld.

This is a female patient with a Class II malocclusion, mild maxillary crowding and mild mandibular crowding, moderate overjet and moderate overbite with an impacted tooth number (#)19. At issue is whether the requested health service/treatment of braces and monthly visits is medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment of braces and monthly visits is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain with nausea, vomiting and urinary frequency

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adolescent female who presented to the emergency room (ER) for abdominal and back pain, nausea and vomiting and urinary frequency. She was seen 4 days prior for the same issues and computerized tomography (CT) scan at that time showed bilateral pyelonephritis. The patient was unable to tolerate oral antibiotics and returned. The patient was afebrile with stable vitals and Creatinine 1.2 and was admitted and administered intravenous (IV) fluids, antibiotics and Zofran for nausea. The patient improved for discharge. 

Per Milliman Care Guidelines (MCG) Health (26th) UTI RRG criteria, the patient fails to meet guidelines for admission to inpatient care. These include hemodynamic instability, altered mental states, persistence or worsening of clinical findings despite observation care. 

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: Bilateral orchitis and large bilateral hydroceles
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a history of hypertension, diabetes, hyperlipidemia and presented to the emergency room with 2 to 3 days of right testicular pain. On presentation, he was tachycardic at 101 but hemodynamically stable. The exam suggested a right scrotal swelling. An ultrasound showed bilateral orchitis and large bilateral hydroceles. He was admitted to the inpatient service and a urology consultation was obtained. Urology recommended antibiotics, urine culture, pain management, scrotal support and outpatient follow-up. The patient had an uneventful hospital course and was discharged home the same day. The medical necessity for an inpatient stay is under review.
The majority of patients who present with testis pain/hydrocele/orchitis renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. A lower level of care for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.