Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female filed a formal complaint regarding the length of time she must wait for a consultation for gastric bypass surgery.  The enrollee has to wait between six and 12 months before her consultation and wants one sooner.  The health plan denied the enrollees request indicating a consultation for the bypass surgery has been approved; however, the enrollee has been advised that it will be six to 12 months before she can see the physician.The physician reviewer has decided that it is not medically necessary for the enrollee to have her consultation for gastric bypass surgery earlier than the expected six- to 12-month wait.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested authorization and coverage of continued chiropractic care for back and neck pain.  The enrollees health plan denied the request indicating that continued chiropractic care is not medically necessary.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage for nasal surgery for a deviated septum and chronic sinusitis.  The enrollees health plan denied the request indicating the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee whose parents requested authorization and coverage for the enrollee to continue treatment with a pediatric nephrologist with a special expertise in focal segmental glomerulosclerosis (FSGS).  The enrollees health plan denied this request indicating that the requested services are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested continued treatment with a pediatric nephrologist with a special expertise in FSGS is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female requested authorization and coverage of Fobi-pouch gastric bypass surgery.  The enrollees health plan denied the request indicating the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the Fobi-pouch surgery is not medically necessary because the Roux-en-Y gastric bypass surgery is the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested authorization and coverage for a Magnetic Resonance Imaging (MRI) study of her knees to diagnose and treat knee pain.  The enrollees health plan denied the request indicating the requested MRI is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee requested authorization and coverage of continued intravenous antibiotic for the treatment of lyme disease.  The health plan denied the enrollees request indicating that long-term antibiotic treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested long-term antibiotic treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of enrollment in a Phase I clinical trial for the treatment a malignant neoplasm of the tongue, head and neck.  The health plan denied the enrollees request indicating that the proposed trial is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that enrollment in the clinical trial is not likely to be more beneficial for treatment of the enrollees cancer than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for the treatment of fibroids.  The health plan denied the enrollees request indicating that UAE is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that UAE is not likely to be more beneficial for the treatment of the enrollees fibroids than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard treatment, the review organization upheld the health plans denial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dilated CBD, distended gallbladder
 
Treatment: Inpatient admission, diagnostic treatment and surgery

The insurer denied the inpatient admission. The denial was reversed.

The patient presented with abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The WBC count was 14.5. The bilirubin was normal. A CAT scan revealed a dilated CBD and a distended gallbladder. An MRCP revealed a CBD stone with bile duct dilatation. The patient was treated with antibiotics. He underwent an ERCP with sphincterotomy and balloon sweeps. A laparoscopic cholecystectomy was then done. The patient remained hemodynamically stable and his pain was controlled.

Acute cholangitis is an indication for admission if there are both systemic signs of inflammation and evidence of common bile duct disease. A WBC count over 10,000 is a listed systemic sign of inflammation. This patient had a WBC count of 14,500 with 92.6% neutrophils. Hepatic imaging showing biliary dilatation or evidence of a stone is listed as evidence of common bile duct disease.

The patient met criteria for admission for gallbladder or bile duct inflammation or stone. IV antibiotics were appropriate in view of the elevated WBC count with left shift.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar Disorder with psychotic features

Treatment: Inpatient admission, and medication management.

The insurer denied inpatient admission. That denial was reversed.

This patient was admitted to the hospital due to psychotic symptoms including hallucinations and persecutory delusional thinking, aggression, and agitation and she reportedly was using cannabis and had a positive toxicology for cannabis and also was using alcohol. It was reported that her WBC was elevated at 21-22.5 and she had a temperature of 100.4. It was reported that she was in the emergency department 2 days prior to this admission. She reportedly had a past psychiatric hospitalization. The psychiatric consultant recommended starting Risperidone as she had a reported diagnosis of Bipolar Disorder with psychotic features and they recommended a psychiatric hospitalization when medically cleared. 

The chart notes provided enough specific evidence to support that she required 24 hour hospital treatment as she was psychotic, aggressive, agitated, and it was not clear if she had a delirium due to an inflammatory response syndrome from a medical condition or from substances or whether this was a primary psychiatric diagnosis as well. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also states that patients with psychotic symptoms, aggressive behavior, severe agitation, suicidal or homicidal ideation, manic episodes, or who present as a danger to self or others are in need of hospital treatment.

In this case this patient had psychotic symptoms including hallucinations and persecutory delusional thinking with agitation and aggression so she was considered a danger to self and others then. Also, she had medical issues including a high WBC and fever and it was not clear if she had a delirium due to an inflammatory response syndrome or from substances or whether this was a primary psychiatric diagnosis as well. Admission was medically necessary
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency department (ED) for rapid heart rate. Troponin showed a level of 0.051, slightly above the upper limit of normal of 0.45. Cardiac catheterization showed left ventricular ejection fraction (LVEF) of 55-60% on left ventriculogram, and normal coronary angiography. The patient was discharged following the procedure.

The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient. Based upon the medical data provided, the patient presented with rapid tachycardia and chest discomfort. Troponin, a measure of myocardial injury, was slight elevated above normal on presentation. As such the patient may have been having a non-ST segment elevation myocardial infarction (NSTEMI). Thus, it was reasonable to admit and monitor the patient in preparation for further investigations including a cardiac catheterization. In view of the elevated troponin and the possibility of developing complications of a NSTEMI, it was medically necessary to admit the patient to full inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

The patient underwent colonoscopy with polypectomy, and subsequently presented to the emergency department later that same day with severe abdominal pain and a syncopal episode. Workup revealed suprapubic abdominal pain to palpation, an elevated white blood cell count of 21, and a computed tomography (CT) scan showing no evidence of perforation but some focal colitis at the splenic flexure. The patient received intravenous antibiotics in the emergency department as part of treatment for post-polypectomy syndrome - and developed red man syndrome as a reaction to vancomycin. Patient symptomatically improved after stopped the vancomycin and treatment with diphenhydramine and famotidine. Patient was admitted as an inpatient for intravenous antibiotics. On hospital day #2 his pain had improved, and switched to oral antibiotics. Patient was felt stable for discharge on hospital day #3. Health plan's determination is upheld.

An inpatient stay was not medically necessary. The patient did not have hemodynamic instability, significant electrolyte abnormalities, nor evidence of peritonitis or perforation from the colonoscopy. Patient most likely had post-polypectomy syndrome which is managed medically with bowel rest and intravenous antibiotics. The patient clinically improved with medical management and was discharged home on hospital day #3. The care provided (e.g. bowel rest, intravenous antibiotics) could have been provided at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adenocarcinoma of the lung

Treatment: Genetic testing

The insurer denied genetic testing Guardant 360. That denial was upheld

This case involves a patient who was diagnosed with adenocarcinoma of the lung.  The patient was recommended to undergo genetic testing.  The patient was seen for a new patient consult after being diagnosed with invasive lung adenocarcinoma.  The patient was noted to be a lifelong smoker.  The physical exam revealed the patient was in no acute distress.  The lungs were clear to auscultation bilaterally.  Considering the patient was symptomatic initiation of chemotherapy was discussed.  He was also recommended the patient undergo imaging to complete staging.  The patient was noted to have a pericardial effusion.  The notes indicate the patient was newly diagnosed. However, there was not enough tissue from the biopsy so there is not a molecular phenotype. Therefore guardant 360 was pending.

According to current literature the use of plasma cell free/circulating tumor DNA testing should not be used in the lieu of tissue diagnosis.  Standards and guidelines for cell free DNA have not been established and there is up to a 30% false negative rate as well as alterations that may be detected that are not related to the tumor.  While the use of this testing may be appropriate in certain circumstances, careful consideration is required to determine whether cell free DNA findings reflect a true driver mutation or an unrelated finding.  Certain testing for rearrangements are recommended for patients with metastatic non-squamous non-small cell lung cancer or non-small cell lung cancer so the patients with these genetic abnormalities can receive effective treatment with targeting agents.  The literature goes on to detail specific mutations such as IDH1 for which this patient was tested, is likely unrelated to non-small cell lung cancer.  While it was noted in the documentation that this patient did not have sufficient tissue for further diagnostics, referenced literature does not detail the requested broad-based panel is considered standard of care.  Specific driver mutations such as EGFR or and ALK gene rearrangements may be recommended. However, as the patient was tested for multiple mutations that are not recommended the requested genetic testing panel was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hypertension, hyperlipidemia, and supraventricular tachycardia (SVT) who presented to the hospital  for elective electrophysiology testing and possible catheter ablation. She had a loop recorder previously implanted, which showed SVT at 190 beats per minute (bpm). She underwent electrophysiologic (EP) testing which was negative for an inducible arrhythmias. 
The health plan's determination is upheld.
The patient was admitted electively for testing, an electrophysiology study and possible catheter ablation. The electrophysiology study was uncomplicated, and as no arrhythmia was inducible; ablation was not performed. Inpatient admission was not required. This could have been handled at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This patient presented with chest pain and no significant findings on ECG or serum blood testing. His pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, he was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1) (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis

Treatment: Laparoscopic appendectomy

The insurer has denied inpatient admission.  The denial was upheld.

The patient was brought in by ambulance to the Emergency Room (ER) complaining of abdominal pain and vomiting.  CT scan of the abdomen was significant for acute appendicitis.  The patient was admitted to surgery service.  He was kept nothing by mouth (NPO) and continued on intravenous (IV) fluids and IV antibiotics.  The following day he underwent laparoscopic appendectomy.  

According to current literature, a patient undergoing an appendectomy is treated as an outpatient.  A patient may be admitted to hospital services when there is severe systemic illness present or there is evidence of poorly controlled co-morbidities or complications from the procedure which necessitate more than 24 hours of postoperative care.  Additionally, if the patient presents to the hospital complaining of abdominal pain and there is evidence of severe persistent vomiting, rebound or guarding, a patient may be admitted to inpatient services.  Within the documentation, none of the above was present.  There is no indication why the patient could not have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient with no pertinent medical history who was referred to the hospital by the  primary care provider because of low hemoglobin.The health plans determination of medical necessity is upheld in whole.The patient did not require admission at an acute inpatient level of care. The care could have been provided in a lower level setting. The inpatient hospital stay was not medically necessary neither the severity of the patient's condition nor the complexity of the services provided were medically necessary for an inpatient level of care, considering patient's overall stability and lack of clinical symptoms.
Appeal type: Medical necessity
Decision: Upheld

The patient had a history of prior syncope and electrocardiogram (EKG) abnormalities, and presented to the emergency department for evaluation of diplopia, headache, and shortness of breath. The patient was admitted. 

The health plan's determination is upheld. The inpatient stay is not medically necessary. The patient was hemodynamically stable, labs were stable with no acute abnormalities requiring inpatient treatment, and head imaging was negative for acute stroke, including a negative brain MRI. There was no evidence of acute cardiac ischemia, acute seizure, encephalopathy or meningitis, or cranial nerve stroke causing diplopia. The patient's syncope required further evaluation but could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The well-established and accepted Kocher criteria to diagnosis septic arthritis of the hip vs. benign toxic synovitis have four criteria:  inability to walk, temperature above 101.3 degrees, ESR > 40 and WBC > 12,000.  This patient met only two of the criteria and therefore had only a 40% chance of having septic arthritis.  Adding the CRP to those criteria, the patient also did not meet that criterion, as his CRP was below the threshhold and it is only considered indicative of septic arthritis when over 2.5.  

An MRI was ordered and was delayed only due to the unavailability of anesthesia.  This was finally done approximately 12 hours after admission.  It was normal, and the patient was discharged eight hours later.  All of his evaluations could have been done as an outpatient.   He did not meet criteria for having a high likelihood of septic arthritis and was proven to not have this.  His discharge diagnosis was toxic synovitis.

The criteria for an inpatient stay were not met.  The patient did not have an infected joint, and the criteria to make this diagnosis were not met at any time.  All evaluations could have been done on an outpatient basis.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with swollen lips for two days after starting amoxicillin for ear infection. This was prescribed by the primary medical doctor (PMD). The patient had fevers for three days at home, mild nonproductive cough and no other lesions other than black crusting on the external lips. No lesions on the buccal mucosa, vaginal or anal mucosa. On examination at the time of admission there was mention of stomatitis on left lateral lower molars with pain to lower posterior molars. The patient was admitted to the pediatric floor for concern for possible Stevens-Johnson syndrome given the nature of the crusting lesion and started on azithromycin for possible mycoplasma stomatitis. Concern was due to rapidly progressing stomatitis. The health plan's determination is overturned.

This patient presented with a febrile illness while on antibiotics and also demonstrated a rapidly progressing stomatitis. The patient had swelling of the lips along with black crusting which raised concern for Stevens-Johnson syndrome (SJS). Given the rapid progression of this disease process along with need for intensive and supportive care, admission to the hospital is reasonable and acceptable care in order to monitor clinical progress. SJS is a condition that is rare but often severe. Mortality is said to be about 10% from SJS. Sepsis, acute respiratory distress syndrome, and multiple organ failure are the most common causes of in-hospital death. If there is concern for SJS, admission and close clinical monitoring with supportive would be prudent until patient is stabilized. For these reasons inpatient level of care was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with diarrhea and vomiting. The patient was well until 3 days prior to admission when the patient developed diarrhea and had more than 10 bowel movements per day.  The patient also developed vomiting, up to 3-4 times per day.  On the day of admission, the patient was noted to have red blood in his stools and was also fussy and had decreased oral intake.  The patient was brought to his primary doctor who noted a positive fecal occult blood test and then sent the patient to the emergency department for further evaluation.

The health plan's determination is overturned.  This infant presented with significant diarrhea and dehydration.  The patient required 3 boluses of normal saline in the emergency department and was still taking insufficient fluid.  The patient was also found to have hypoglycemia and required inpatient admission for continued intravenous hydration as well as close monitoring of his glucose and clinical status, with additional treatment as needed.  The decision making at the time of admission was consistent with his young age, the presence of diarrhea, vomiting, and dehydration, and the need for ongoing fluid resuscitation with close monitoring for potential deterioration of clinical status.