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

This is a patient with a Class I occlusion, mild maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite with bimaxillary protrusion. At issue is the medical necessity of braces.
The health plan's determination is upheld.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include a cleft palate deformity or cranio-facial anomaly, 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 patient 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, braces are not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female. She has h/o (history of) sleeve gastrectomy. She has not been taking any iron supplements since surgery, has been on Nexium 40mg PO (oral) daily. She was sent to the ED by her PCP (primary care provider) for low Hb/Hct (hemoglobin/hematocrit). She was c/o (complaining of) progressive weakness, lethargy, and fatigue for quite some time. Her Hb on the lab done in her PCP's office was 5.0. 

In the ED, the patient was hemodynamically stable and afebrile. She denied any h/o nausea, vomiting, hematemesis, melena, rectal bleed. Her CBC (complete blood count) revealed Hb/HCT 4.9/20.3. Her Ferritin levels were low. There was no evidence of overt bleeding. She was given three units of PRBC (packed red blood cells), and IV iron infusion. The GI (gastroenterology) and hematology were consulted. The GI consultant recommended outpatient GI evaluation with EGD (esophagogastroduodenoscopy)/colonoscopy after blood transfusion. Her Hb/HCT were 11.2/33.4. She was tolerating her diet well during her stay in the hospital. 

The patient was discharged home in fair and stable condition, as the patient wanted to go home due to family reasons. She was discharged home on iron supplements and Nexium, and advised to follow up with GI and Hematology.

The patient was sent to the ED by her PCP for low Hb of 5, found on CBC done by her PCP. The patient was c/o progressive lethargy, fatigue and weakness. She had h/o sleeve gastrectomy. She took multivitamins and iron supplements initially, and then stopped taking them. She denied any overt bleeding in the form of hematemesis, melena, hematochezia. In the ED, she was hemodynamically stable and afebrile. She was found to be profoundly anemic due to severe iron deficiency anemia and was given three units of blood and iron infusion. Since the patient was hemodynamically stable and had no signs and symptoms of overt GI bleed, the GI consultant recommended outpatient GI work-up. She was discharged home on iron supplements and Nexium. In view of this clinical scenario, the acute level care was not appropriate and medically necessary, and she could have been safely managed at the lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Ear/Nose/Throat- Dizziness/vertigo
Inpatient hospital stay


The patient has no significant past medical history (PMHx) and presented to the emergency department (ED) on with complaints of dizziness, nausea, vomiting and headache. The patient reported the symptoms began intermittently but were now constant. On arrival vital signs (VS) noted as Temperature 98.7, heart rate (HR) 76, respiratory rate (RR) 18 and blood pressure (BP) 143/89. The physical exam (PE) noted a normal neurologic exam. Labs noted Creatinine 1.0, sodium (Na) 141, potassium (K) 4.3, white blood cell count (WBC) 11.76, Hemoglobin 12.9, and platelets (Plt) 197. A computed tomography (CT) of the head was negative for an acute intracranial process. The patient was admitted with plans to treat vertigo and vomiting with meclizine and Zofran as well as consult neurology and obtain a magnetic resonance imaging (MRI). The patient was seen by neurology and physical therapy (PT). Patient was found to have a positive Dix-Hallpike test. The test was positive for left sided benign paroxysmal positional vertigo. Patient then underwent Epley maneuver which led to improved symptoms. Patient was discharged the following day with meclizine and vestibular rehab for management of benign paroxysmal postural vertigo (BPPV). The health plan's determination of medical necessity is upheld in whole. The patient presented with symptoms of vertigo. There were no VS abnormalities, no CT abnormalities, and no persistent neurologic deficits. The patient had no lab abnormalities to explain the presentation. Patient was seen by neurology and physical therapy, and was found to have a positive Dix-Hallpike test. Patient then underwent Epley maneuver which led to improved symptoms. Patient was discharged the following day with meclizine and vestibular rehab for management of benign paroxysmal postural vertigo (BPPV). According to Milliman Care Guidelines (MCG) criteria, this patient did not meet inpatient criteria as there were no persistent neurologic deficits (1). It would be appropriate to admit this patient to a lower level of care to ensure the mental status continued to improve, however, the patient did not meet acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible TIA
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an elder female. She presented to the emergency ward with the complaint of transient left sided numbness, slurred speech and facial droop.  At presentation, her neurological examination and CT brain were normal. She was admitted for stroke evaluation. 

The patient presented with transient neurological symptoms with a negative evaluation. The diagnostic studies, monitoring, consultations and treatment could have been safely and effectively completed at a lower level of care. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain, Shortness Of Breath, And Left Sided Weakness
Treatment:  Inpatient admission

The Inpatient admission was not medically necessary.

The patient is a male.  He has a past medical history significant for CVA (cerebrovascular accident) with residual left sided weakness, carotid stenosis, s/p (status post) CEA (Carotid Endarterectomy), dyslipidemia, asthma, anxiety, tobacco and drug abuse.  He presented to the ER with complaints of left-sided chest pain and left-sided weakness. 

The patient was hemodynamically stable.  The ECG (electrocardiogram) revealed no acute ischemic changes. Cardiac enzymes were negative.  Head CT was negative for intracranial bleeding or acute infarction.  Chest X-ray revealed no acute pulmonary disease.  The patient was seen in consultation by cardiology, and nuclear stress test was recommended.  Nuclear stress test was normal.  Neurology consultation noted history of CVA with left-sided weakness and numbness.  MRI of the brain was obtained and was negative for acute pathology. 

The patient was discharged home with recommendation for outpatient follow-up.


This patient presented for evaluation of atypical chest pain.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. Ischemia was ruled out by stress testing.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  There was no evidence of CVA (cerebrovascular accident) or intracranial bleeding.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male who presented to the hospital for further evaluation/management of chest pain. Intake vitals were afebrile, hemodynamically stable. Examination was non-focal with no significant abnormalities seen. Electrocardiogram (EKG) and cardiac enzyme biomarkers were without significant abnormalities. Medical records indicate the patient was admitted solely for observation/monitoring and treated with intravenous (IV) proton pump inhibitor (PPI) therapy, as needed (PRN) analgesics and anti-emetics with significant improvement in symptoms. 

The patient presented to the hospital for further evaluation/management of chest pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, profound tachycardia, hypotension or malignant hypertension. Examination was non-focal with no significant abnormalities seen including no evidence of end organ damage. EKG and cardiac enzyme biomarkers were without significant abnormalities including no evidence of significant arrhythmia, ST segment deviations or other findings concerning for acute coronary syndrome. Medical records indicate patient was admitted solely for observation/monitoring and treated with IV PPI therapy, PRN analgesics and anti-emetics with significant improvement in symptoms. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Substance Abuse
Inpatient Mental Health

This is a patient who was medically screened in the emergency department and then admitted for acute inpatient psychiatric treatment . The patient had become increasingly depressed with suicidal ideation with a plan to hang himself and with deterioration in functioning culminating in his presentation. He had a history of bipolar disorder and severe depressive episodes and psychiatric treatment with therapy and medications, as well as past treatment with electroconvulsive therapy (ECT). His presentation was characterized by worsening symptoms of depression and suicidal ideation in the context of multiple psychosocial stressors and substance use disorder with cannabis, as well as past use of alcohol and hallucinogen (lysergic acid diethylamide (LSD) and Mushrooms) class substances of abuse.
The mental status examination revealed a sad affect and anxiety including apprehension, nervousness, tension, irritability, and excessive worry. The patient's sleep, appetite, energy levels and volition were disturbed. He exhibited depressed mood with suicidal ideation, hopelessness and anhedonia. He was withdrawn with motor agitation. There was no psychosis or other signs of cognitive impairment or perceptual disturbance. His judgment was markedly impaired, and his suicidal risk was judged to be moderately severe with poor control of impulses and limited insight together with his struggles with maintaining abstinence.
The patient continued to exhibit severe symptoms of depression with dysphoria and labile affect. He had bouts of mood cycling with grandiose thinking, pressured speech and flight of ideas with excitability. His medications were titrated with plans for ECT. However, his evaluation revealed signs of hydrocephalus and the plans for ECT were cancelled. His medications were adjusted. During this time frame, the patient displayed bouts of agitation with depressive turmoil requiring re-direction and continued safety monitoring. He was anxious with labile affect and passive suicidal ideation, as well as continued insomnia and motor agitation.  
The health plan's determination is overturned.
The patient required the continued acute inpatient level care in this case scenario. The continued structure of an acute inpatient level setting through discharge was warranted in order to provide safety monitoring and to continue active treatment for his psychiatric disturbance while conducting an evaluation, and while observing his functioning with the resumption/adjustment of clinically appropriate medications.
The medical necessity for acute inpatient level structure and monitoring is reasonable and in the patient's best interest in view of the patient's severe symptoms of mood disorder and co-occurring substance use disorder and high risk for suicidal behavior; in view of the persistent symptoms of bipolar mood disorder with mixed features of mania and depression and the severe psychosocial stressors; and, in view of the need for continued active treatment in the context of deteriorated functioning and severe stressors.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic
Treatment: Ambulance

At the time of service the patient  was admitted to the hospital for placement of inferior vena cava (IVC) filter and then underwent extensive spine surgery for a revision posterior spine surgery Cervical (C)2 to the pelvis including plastic surgery performing a left pedicled latissimus and rhomboid major flap. The recovery was prolonged and necessitated a rehabilitation stay at a Rehab Center. Discharge diagnoses included acute blood loss anemia, placement of IVC filter, chronic obstructive pulmonary disease (COPD), history of (H/O) pulmonary embolism, demand cardiac ischemia. At the time of discharge  precautions were use of Miami-J Cervical collar at all times and using log-rolling techniques when getting out of bed. No sitting restrictions were noted in the discharge summary. The patient was documented by physical therapy (PT) to be walking 50 feet with a RW (rolling walker) using oxygen by nasal cannula.
The questions for this review revolve around the numerous ambulance rides taken by the patient to and from the rehabilitation center to various doctor offices.
The health plan's determination is upheld in whole. There were no sitting restrictions placed on the patient upon discharge from surgery, and the patient was walking 50 ft with a RW before that discharge. There was no documentation of any deterioration in  medical condition or physical abilities that would have precluded the patient from being transported in a wheelchair by alternative forms of transportation. At least 2 of the ambulance crew notes documented that the patient was ambulatory. While the patient required nasal O2, that could have easily been supplied in a wheelchair setting.  No specific medical interventions were performed during any of the ambulance rides.  All of this documents that the patient was medically stable for transport to and from the appointments in alternative forms of transportation.
Appeal type: Medical necessity
Decision: Upheld

The patient has an extensive past surgical history (appendectomy, gastric bypass, cholecystectomy) who presented to the emergency room (ER) with right lower quadrant (RLQ) pain. The patient had stable vital signs and her labs were unremarkable. The patient's urinalysis (UA) was positive. A computed tomography (CT) scan of the abdomen and pelvis was completed and was normal. The patient was admitted for a possible urinary tract infection (UTI) and started on intravenous (IV) antibiotics and for a bariatric surgery consult. The patient was able to tolerate oral nutrition (po), her pain was controlled with oral medication, no surgical intervention was needed, and she was discharged home with oral antibiotics (abx). 

At issue is the medical necessity of the inpatient admission. 

The health plan's determination is upheld. The patient presented with abdominal pain and was diagnosed with a urinary tract infection and started on antibiotics. A surgical consult was obtained which did not determine the need for a surgical intervention. The patient was able to tolerate po, the pain was controlled with oral medications and the patient was discharged home with oral antibiotics within 23 hours. An acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient admitted with a listed diagnosis of decreased vision in the right eye. She has a prior history that includes hypertension, asthma, and a pituitary tumor. The patient reported progressive left eye blurring of her vision. She had seen a neuro-ophthalmologist who reported a "swollen" left optic nerve. The patient was started on intravenous SoluMedrol and was admitted for further testing.

At issue is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The submitted medical records do not support the need for an inpatient stay. There is no evidence that the patient could not have safely been evaluated and treated a lower level of care. There is no evidence that the patient had an uncontrolled fever or signs of an overwhelming infection, major changes in level of consciousness or awareness, and no evidence of life-threatening arrhythmias or major electrolyte disturbances. There was no documented hemodynamic instability, new or worsening organ(s) failure(s), danger or threat to self or others, or any other situation/condition requiring inpatient management. There were no advanced or high-risk tests, treatments or infusions documented.

The patient had four days of left eye symptoms, thought to be due to an optic neuritis. The current standard of care for the treatment of acute optic neuritis is either no treatment, or intravenous (IV) Methylprednisolone infusions, which can be safely done as an outpatient, or alternatively, under observation status or in an infusion center. Osborne and Balcer, in a recent review of the treatment of optic neuritis stated "Many patients can now be treated with home intravenous infusions of Methylprednisolone for episodes of optic neuritis. The side effects of treatment are minimal when given for a brief time course. The most common side effects in the ONTT (Optic Neuritis Treatment Trial) were mood changes, facial flushing, sleep perturbations, weight gain, and dyspepsia." Furthermore, Chataway et al, in a comparison study between in home and in hospital steroid administration, have shown safety and efficacy of in-home intravenous steroids administration. They reported "Treatment of relapses in multiple sclerosis with intravenous steroids can be effectively and safely administered at home, from both patient and economic perspectives." The option for no treatment is based on several trials, and one meta-analysis of three trials "that compared treatment with intravenous Methylprednisolone to placebo and found no benefit of treatment on visual outcomes at six months and at one year" (Gal et al).

Therefore, the records do not support the need for inpatient level of care during the period under review.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with migraine headaches. As prophylaxis against her migraine headaches, she has tried several medications, including cyproheptadine, nortriptyline, and topiramate. All of these medications have failed to prevent her headaches. In an attempt to relieve the patient's migraine headaches, her pediatric neurologist has prescribed Emgality. The health plan denied the Emgality as not medically necessary. At issue is the medical necessity of the Emgality.
The health plan's determination is upheld.
Calcitonin gene related peptide (CGRP) is a naturally-occurring peptide that has potent vasodilating properties. Strong scientific evidence suggests that CGRP plays an important role in migraine headache pathophysiology, through its actions of vasodilation. Agents that can suppress the activity or concentration of CGRP could improve migraine headaches. Emgality is a humanized monoclonal antibody directed against CGRP. Clinical trials have demonstrated that Emgality can reduce the frequency and severity of migraine headaches. Emgality is Food and Drug Administration (FDA)-approved for prophylaxis against migraine headaches. However, it is customary to try other conventional medications before using monoclonal antibodies, such as Emgality. A number of other medications that can be effective as prophylaxis against migraine headaches have not yet been tried by the patient. These include amitriptyline, valproic acid, and venlafaxine.
Preferred medications have not been tried. These include beta blockers (propranolol, metoprolol, timolol, nadolol, and atenolol), the anticonvulsant divalproex, and antidepressants (amitriptyline and venlafaxine). In her letter of medical necessity, her provider states that the beta blockers (propranolol, metoprolol, timolol, nadolol, and atenolol) are all contraindicated because the patient is dizzy at baseline. However, beta blockers are not contraindicated in patients with dizziness. The provider also notes that valproic acid is contraindicated in women of child-bearing age. Valproic acid must be used with caution in pregnant women, but is not contraindicated solely because a woman is of child bearing age. Amitriptyline is a commonly-used medication for migraine headaches and has not yet been tried by the patient. Likewise, venlafaxine has not yet been tried. Therefore, there are many preferred medications that are safe and effective and could help the patient's migraine headaches but have not yet been tried. Thus, Emgality is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Hypertension
Inpatient hospital

This is a female with history of hypertension and obesity who presented to the emergency department (ED) with complaint of sudden onset of epistaxis. Initial vital signs were blood pressure (BP) 180/104, pulse 70, resp 20, pulse oximetry 100% on room air, and temp 99.6 F. Physical examination showed bilateral nostril packing with 2+ pedal edema. Abnormal lab values included glucose 136, anion gap 16. An electrocardiogram (EKG) showed normal sinus rhythm with t-wave inversions in V3-V6. Chest x-ray showed probable slight bilateral dependent atelectasis. The patient was admitted and seen by Cardiology, ear, nose, and throat (ENT) and critical care. She was treated with nasal packing and blood pressure medications. The patient was discharged home with outpatient follow-up. In question is the medical necessity of the inpatient admission.

The health plan's determination is upheld. The Inpatient hospital admission was not medically necessary. Although the patient presented with hypertensive urgency and nasal bleeding, this was well controlled while the patient was in the emergency department. The nasal bleeding was controlled with anterior packing and the blood pressure was under control with medications administered in the ED. Further care consisted of a Cardiology consult, echocardiogram and blood pressure monitoring. The blood pressure remained stable and outpatient follow-up was recommended by Cardiology. There were no inpatient clinical needs that met criteria for inpatient admission.