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

This is a patient with a history of asthma who was brought to the emergency department (ED) with the onset of facial swelling, lip swelling, hoarseness, throat itchiness, and rash within minutes of eating crab and shrimp. At the time of triage, he was afebrile, he had a heart rate (HR) of 96, a respiratory rate (RR) of 23, a blood pressure (BP) of 115/89, and an oxygen saturation of 98%, with swelling of the eyes and lips. The physician provider noted that he has periorbital and facial swelling, upper and lower lip swelling, rash, and clear lungs. In the ED, he was given Epinephrine, Dexamethasone, Benadryl, and Pepcid, and was then admitted to the pediatric floor for monitoring. He did well overnight, without the need for any further treatment, and was discharged home with an Epipen, Prednisolone, and Benadryl.
At issue is the medical necessity of the inpatient admission .
The health plan's determination is upheld.
This patient presented with an allergic reaction to shellfish. It is unclear whether the patient met the American Academy of Allergy, Asthma and Immunology's criteria for anaphylaxis, which requires involvement of at least two of the four domains: skin/mucus membranes (e.g. itching, flushing, hives, edema); respiratory compromise (e.g. shortness of breath, wheeze, stridor, hypoxemia); hemodynamic (e.g. syncope, collapse, hypotension); and gastrointestinal (vomiting, diarrhea, pain). This patient had skin/mucus membrane involvement, but did not have evident respiratory, hemodynamic, or gastrointestinal effects. Nonetheless, it was still reasonable to treat the patient for possible anaphylaxis in the ED, as the guidelines state that "there is a broad spectrum of anaphylaxis presentations that require clinical judgment," and recommends that if a patient has possible anaphylaxis, Epinephrine should be administered as soon as possible, an intravenous (IV) line should be started, and monitoring should be ongoing. Further management is based on the initial response. If there are persistent or new symptoms, then fluids, steroids, bronchodilators, H1 and H2 blockers, and further Epinephrine are considered. In this case, the patient in the ED was provided these further treatments. Afterward, the guidelines recommend a period of observation in the ED for the development of worsening symptoms, new symptoms, or lack of improvement of the initial symptoms--only if this occurs does the guideline recommend hospitalization.
In this case, the patient did not clearly have anaphylaxis, but was still treated for anaphylaxis. During the period of ED observation, he did not have any of the guideline criteria that would require hospitalization. He did not need further treatment. If the treating physicians in the ED wished to observe him a longer period of time, care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal
Treatment:  Inpatient Hospital

This is a patient with an esophageal foreign body that required removal in the operating room.  He presented to the emergency department (ED) with a concern for a swallowed coin.  Vital signs were stable.  He underwent an uncomplicated esophagoscopy with foreign body removal.  There were no operative or perioperative complications.  He was discharged home.  At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld.  The child had stable vital signs and no concern for any serious aero-digestive injury.  He underwent an uncomplicated procedure without any peri-operative concerns.  He could have been managed at a lower level of care than inpatient.  Esophagoscopy with foreign body removal in an otherwise healthy child is typically done under an ambulatory status.  In this case, there were no airway concerns.  The child had a normal esophagoscopy after the penny was removed.  He did not have immediate peri-operative complications.  There was no medical documentation showing that inpatient status was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left lower abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is upheld.
The proposed treatment -- admission at an acute inpatient level of care - was not medically necessary.

The patient is a male. His medical history included diverticulitis requiring intravenous antibiotics in an outpatient level of care. His surgical history was negative. 

The patient presented to an emergency department with left lower quadrant abdominal pain and headache. His vitals were temperature 36.9, pulse 80, blood pressure 124/73, respirations 18, oxygenation 99%. Physical examination demonstrated tenderness to palpation in the left lower quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 13. Computed tomography demonstrated sigmoid diverticulitis with "phlegmon or developing abscess". Following consultation with General Surgery, the patient was advised to be admitted at an acute inpatient level of care for treatment for his recurrent sigmoid diverticulitis. However, the patient left against medical advice. 

In the absence of significant complications or co-morbidities, or severe anatomic or physiologic derangements, there was no need to admit the patient at an acute inpatient level of care.  He could have been managed at a lower level of care. 

According to the American Society of Colon and Rectal Surgeons, "nonoperative treatment typically includes oral or intravenous antibiotics and diet modification" -- all of which can be completed on an outpatient basis [Feingold et al.]. 

Based on the patient's medical condition and diagnosis, and national guidelines, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, chills, groin pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.
The proposed inpatient admission was medically necessary.

The patient is a female whose inpatient hospital admission is under review. The patient presented to the emergency department (ED) with fever and chills for one day. No headache, neck pain, chest pain, cough, runny nose, ear pain, sore throat, abdominal pain, vaginal discharge, or back pain was noted. The patient did have groin pain.

Temperature (T) - 98.6   
Pulse (P) - 84    
Respiratory rate (RR) - 20    
Blood pressure (BP) - 96/65
Chest - normal
Cardiovascular system (CVS) - normal 
Abdomen - soft, non-tender (NT), normal bowel sounds, palpable mass on the right (R) side, mildly tender centrally
Skin: vesicles left (L) foot/ankle. R foot evidence of resolved vesicle.

The patient's labs revealed the following:
White blood cell (WBC) - 25.58 (high)
Hemoglobin (Hg) - 12.8
Hematocrit (Hct)- 39.7
Platelets (Plt) - 244
Sodium (Na) - 139
Potassium (K) - 3.9
Chloride (Cl) - 103
Carbon dioxide (CO2) - 28
Blood urea nitrogen (BUN) - 14
Creatinine (Cr) - 1.0

Pelvic ultrasound (u/s) showed fibroids, complex nabothian cyst with debris or hemorrhage, and normal ovaries.  Endometrium was not visualized. Computed tomography (CT) of the abdomen and pelvis showed mild right sided hydronephrosis and mild dilatation of proximal right ureter; enlargement of the uterus.  Chest c-ray (CXR) was normal.
In the emergency room, the patient was thought to have leucocytosis due to an occult infection (abdominal gynecologic, urologic, and skin infections considered). The patient was started on intravenous (IV) vancomycin and Zosyn, and was admitted. During admission, it became clear that the patient had a right lower extremity (RLE) cellulitis; treatment was tailored to this and she was discharged.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (IDSA) (1), as she had systemic signs of infection (fever and leucocytosis). Beyond that, when she was first seen, the treating physicians could not localize the infection. Standard of care in these cases would require close inpatient observation and treatment. Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth infection
Treatment: Root canal tooth #15
The insurer denied the root canal tooth #15.
The denial is overturned.

The proposed root canal tooth #15 is medically necessary. 

The x-ray presented of the tooth shows a deep existing composite filling very close to the nerve. The tip of the tooth (apex) has a hint of a shadow showing, which would be indicative of an infection in the tooth. A root canal specialist has determined the tooth needs a root canal treatment. This tooth does not need to be extracted and a root canal procedure is to be considered medically necessary to save it.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Spinal stenosis
Treatment: Lumbar stabilization device
The insurer denied the Lumbar stabilization device.
The denial is upheld. 

The patient is a female with history of chronic low back pain radiating into both legs and made worse with standing and walking with intermittent claudication and improvement with lumbar epidural steroid injections. She has also tried Tramadol, Tylenol, Meloxicam and home exercise program. A diagnosis of lumbar stenosis and lumbar radiculopathy was made. She is not a candidate for open surgical decompressive surgery.

The MRI Lumbar spine showed moderate central canal stenoses at L2-L3 and severe stenosis at L4-L5.

Her treating physician is requesting performing lumbar interspinous spacer device at L4-L5 without decompression or fusion.

No, the health plan should not cover the proposed lumbar interspinous spacer device at L4-L5 without decompression or fusion.

There is no evidence in the literature of clear and significant effectiveness of the procedure in treating lumbar spinal stenosis. In the study by Zaina, it was stated that Cochrane analysis showed low-quality evidence from a single study including 191 participants that favored the interspinous spacer versus usual conservative treatment at six weeks, six months and one year for symptom severity and physical function. In the study by Tekmyster, low back pain severity improved from 76.8  22.2 mm preoperatively to 39.9  32.3 mm at 12 months with only 48% improvement.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Spinal stenosis
Treatment: Lumbar stabilization device
The insurer denied the Lumbar stabilization device.
The denial is overturned. 

The patient is a female with history of severe spinal stenosis and neurogenic claudication, who is trying to avoid spinal surgery.  Other options include decompression with instrumentation and MILD (minimally invasive lumbar decompression), which was denied.  The patient is trying to avoid invasive surgery.  The patient has failed conservative treatments in the form of PT (physical therapy), Medications, and epidural steroid injections.  

Yes, the health plan should cover the proposed treatment.

The patient is a female in whom a Vertiflex Superion (Insertion of lumbar interspinous process stabilization device without decompression or fusion) has been offered for the treatment of symptomatic moderate neurogenic claudication from lumbar spinal stenosis at L4-5.  The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, pain medications. The patient was offered an alternative surgery in the form of a lumbar laminectomy/decompression but is trying to avoid invasive surgery. She was offered a MILD procedure (minimally invasive lumbar decompression) but this was denied.  Open surgery is obviously a considerably more invasive procedure, and it often reduces and restricts the patient's mobility after surgery and can limit their ability to return to gainful employment, especially if it involves manual labor.  Therefore, the patient's options are limited.  

The patient does have radiographic evidence of significant spinal stenosis limited primarily to one level, the L4-5 level.  The patient has had good responses to epidural steroid injections, however they have been short-lived.  Therefore, with the exception of more invasive surgical laminectomy, the interspinous process stabilization (Vertiflex Superion) is the only other option that the patient has not failed.  Patient has had epidural steroid injections, physical therapy, and the other options that have been shown to be helpful in the literature. 

Vertiflex Superion (VS) has been shown to be effective in multiple peer-reviewed articles.  It is been shown to be as effective as lumbar laminectomy at five years.  Risks of the procedure are much less compared to conventional "open surgery."  Postoperative recovery time is much shorter, and lumbar range of motion is preserved compare to instrumentation.  Given the above, the requested VS is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial clot.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case is a female with a history of breast cancer.  She was treated with lumpectomy and adjuvant chemotherapy.  She completed treatment.  She had a routine echocardiogram performed on an outpatient basis and a 3.5 centimeter (cm) right atrial clot was identified.  When this was identified she was sent to the emergency department.  Vital signs at that time were unremarkable.  

Computed tomography (CT) of the chest was performed and revealed no pulmonary embolism but it did reveal adherent thrombus in the right atrium.  The catheter of her port was adjacent to this thrombus.  She was started on intravenous heparin and admitted to the hospital.   

Cardiothoracic surgery was consulted and recommended removing the port.  Interventional radiology removed the port.  Following that, the patient was transitioned to Lovenox given twice daily and she was discharged home.  She had borderline low blood pressure during her hospital stay that was noted to be at her usual baseline.

No, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.  

This patient was evaluated because of right atrial thrombus noted on a routine echocardiogram.  This was associated with her port.  She had no pulmonary embolism and no hemodynamic instability.  Cardiothoracic surgery only recommended port removal.  The patient was admitted and anticoagulated and after port removal was discharged on continued anticoagulation.  She could have been treated at a lower level of care and did not require acute care inpatient admission.  She did not require any intervention other than removal of the indwelling port and therapeutic anticoagulation.  These interventions do not require acute care hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure

Treatment: Hospital admission 
 
The insurer is denied coverage for hospital admission.

The denial is upheld. 

This is a male patient with a history of mechanical aortic valve replacement, non-ischemic cardiomyopathy with left ventricular ejection fraction (LVEF) 40%, biventricular implanted cardioverter defibrillator, paroxysmal atrial fibrillation, hypertension, hypothyroidism, aortic aneurysm, depression, and back pain. The patient presented to the Emergency Department (ED) with a one week history of dyspnea, cough, back tightness, and orthopnea that began with an upper respiratory infection (URI) treated as outpatient with nasal spray and Robitussin. In the ED, the patient's initial vital signs included blood pressure 162/95, heart rate 72, respiratory rate 20, temperature 97.4 F, and oxygen saturation on room air 98% on room air. The patient's examination did not reveal wheezes, rales, murmurs or edema. The patient's electrocardiogram (EKG) revealed atrial sensed ventricular paced rhythm. The patient's laboratory test results included creatinine 1.1, sodium 145, potassium 3.4, hemoglobin 11.5, pro-BNP 2169, and INR 1.7. The patient's initial troponin was 0.052, with subsequent troponin levels 0.046. As per Cardiology note, this troponin trend was considered to be a mild troponin leak due to acute congestive heart failure (CHF) exacerbation and not due to myocardial ischemia. The patient's computed tomography angiography (CTA) of the chest revealed cardiomegaly, pleural effusions, and patchy airspace opacities consistent with pulmonary edema. The patient's echocardiography revealed a well seated bioprosthetic aortic valve, dilated aortic root, and mild left ventricular dysfunction (LVEF 40%). The patient was treated with intravenous Lasix 40 mg, with improvement in his symptoms and was discharged home on his home medications, plus oral Lasix, Protonix, iron and stool softener.

Based on the review of the medical record and literature, there is no evidence that an inpatient hospital admission was medically necessary to treat this patient's acute on chronic heart failure. According to MCG guidelines for heart failure (M-190), inpatient admission is clinically indicated for conditions that include hemodynamic instability, severe electrolyte abnormalities requiring inpatient care, cardiac arrhythmias of immediate concern, acute myocardial ischemia causing or associated with failure, pulmonary edema that is severe and require oxygen supplementation, and/or dyspnea that persists despite emergency department or observation care treatment. In this case, this patient was hemodynamically stable and could have been treated with intravenous Lasix in the Emergency Department or as observation status. Thus, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

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

Diagnosis Irritable Bowel Syndrome
Treatment: Vyberzi
The insurer denied Vyberzi
The determination is overturned.

This is a patient with a diagnosis of irritable bowel syndrome with diarrhea (IBS-D). She has had a fairly comprehensive work up to exclude other causes of chronic abdominal pain and diarrhea. The patient has also used Imodium with incomplete benefit. She underwent a computed tomography (CT) of the abdomen which demonstrated mild, non-specific thickening of the distal transverse and descending colon. Lomotil is contraindicated due to the potential for drug-drug interactions with her psychiatry medication. The patient's provider has recommended treatment with Vyberzi 75 milligrams (mg), however, this treatment was denied by the plan. The medical necessity of Vyberzi is under review.
The patient has had a comprehensive work-up and the diagnosis of irritable bowel syndrome with diarrhea (IBS-D) is correct. The management of IBS-D includes anti-spasmodics, anti-diarrheals, rifaximin, selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressants (TCA), alosetron, and eluxadoline (Viberzi). [1]. The patient has tried and failed non-specific anti-spasmodics and anti-diarrheals. Due to bipolar disorder, she is not a candidate for SSRI or TCA therapy. Alosetron [2] and eluxadoline [3] are the drugs with the strongest evidence to support efficacy, which are both not on the formulary. However, the formulary alternatives including hyoscyamine, chlordiazepoxide, clidinium have not been shown to be superior to placebo in randomized trials. Therefore the eluxalodine is medically necessary and the patient would benefit significantly from eluxadoline.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

The patient is a female who presented to the emergency department (ED) with chest pain. The pain was described as constant pressure started 3 weeks ago, 8/10 in severity. The pain was radiating to left arm and neck and was worse with exertion and movement. Worse with laying down and better with sitting at 30 degrees. The patient also productive cough for 3 days with yellow phlegm.

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with atypical chest pain. She has multiple coronary risk factors, including hyperlipidemia and smoking. Her troponin was normal. Her Echo was unremarkable. The chest pain was suggestive of pericarditis. A CTA of the coronary arteries did not reveal significant obstructive disease. The patient recently was in another hospital with the same complaints and had a diagnosis of pericarditis.
Because the patient's condition was stable, she had symptoms caused by pericarditis and she required only oral medications, an inpatient level of care was not indicated. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atypical chest pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

Yes, the Inpatient admission is "medically necessary".

The patient is a male with a past medical history significant for HTN (hypertension), dyslipidemia, GI bleeding, anemia, CAD (coronary artery disease), s/p (status post) multiple stents, end-stage renal disease, s/p failed renal transplant, on HD (hemodialysis), diabetes mellitus, who presented to the ER with complaints of chest pain, dyspnea and melena. 

The patient was hemodynamically stable. Troponin was elevated at 0.44, suggestive of myocardial injury. Laboratory data was otherwise significant for severely elevated glucose of 697, potassium of 6.6, hemoglobin of 8.3 and BUN (blood urea nitrogen) of 125. 

The patient was admitted for suspected ACS/NSTEMI (acute coronary syndrome/non-ST-elevation myocardial infarction), uncontrolled diabetes with severe hypoglycemia and hyperkalemia. Nephrology and cardiology consultations were obtained. Insulin was used for diabetes management and bicarbonate was given intravenously. Patient was referred for urgent hemodialysis. Cardiac catheterization was performed, revealing totally occluded LAD (left anterior descending artery), with reconstitution via collaterals. Prior stents were patent with diffuse distal disease. The patient was treated medically for CAD and was discharged home.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD, including poorly controlled diabetes, as well as a known history of coronary artery disease, requiring percutaneous revascularization. The patient also had significant electrolyte imbalance with severe hyperkalemia and required urgent hemodialysis. He also had severe hyperglycemia, requiring urgent therapy with insulin. There was a high index of suspicion for an ACS, and a cardiac catheterization was performed. Given the presentation, uncontrolled diabetes, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.