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

Diagnosis: Fibula Fracture

Treatment: Inpatient admission
 
The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a past medical history of an open reduction internal fixation (ORIF) of her left leg and post-polio syndrome. She presented to the Emergency Department with complaints of pain to the right foot; the patient had sustained injury. The patient's x-ray demonstrated a fracture to her distal fibula. The patient was admitted to the hospital and orthopedic consultation was provided. Their recommendation was a short leg cast. The patient was discharged from hospital after a period of medical stability.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient had sustained right ankle fracture. The patient was found to have fractured the distal fibula with associated ligamentous damage (i.e., stress view showed widening). This injury is common and not complex. The patient did not require anesthesia for closed or open reduction. The patient was treated by Orthopedics with application of a short leg cast. This management could have been provided in an outpatient setting. It could have also been completed in a physician's office. There were no other medical problems which required inpatient management. The patient did not report pain and was able to tolerate oral medications. The patient's physical therapy (PT) services could have been provided at a lower level of care. Mobilization could also have been provided by wheelchair.  No additional testing or specialized consultation was required. There were no extenuating circumstances to substantiate acute level admission for the diagnosis of closed ankle fracture. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a male requesting orthodontic benefits.

Yes. The braces are medically necessary.

Tooth #7 (upper right lateral incisor) is in crossbite with the lower tooth. This is an automatic qualifier for benefits according to the handicapping index scale. If this is not corrected, there is increased probability that the tooth will fracture. Orthodontic treatment is needed to correct the problem.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Abdominal pain
Treatment: Inpatient Stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

This is a male with history of henoch-schonlein purpura who presented to the emergency department (ED) with complaints of nausea, vomiting and abdominal pain. The patient was also unable to tolerate oral intake due to abdominal pain. Vital signs were temperature 36.7 C, pulse 79, pulse oximetry 100%, respirations 17, and blood pressure (BP) 137/87. Physical examination revealed scattered petechiae on soft palate with mild diffuse abdominal tenderness and a diffuse purpuric rash on arms and legs. Abnormal laboratory values included positive rhinovirus, glucose 170, total bilirubin 1.7, C-reactive protein (CRP) 6.8, white blood cell (WBC) 13.2, platelets 149, and lactate 2.66. 

The Inpatient Hospital Stay was medically necessary for this patient. This patient showed evidence of hemodynamic instability with a lactate level of more than 2.5 mmol/L, which is indicative of inadequate systemic perfusion. This patient was hemodynamically unstable and required inpatient monitoring and treatment. Based on Milliman Care Guidelines (MCG) for Abdominal Pain, Undiagnosed ORG, a lactate level of 2.5 or more is considered a severe vital sign abnormality that meets criteria for inpatient admission. In addition, a lactate level of 2.5 or more is evidence of inadequate systemic perfusion. This patient was treated with intravenous fluids, steroids and pain medication, which was appropriate for his condition with significant improvement on the following day. Based on available medical records, the inpatient admission was medically necessary since the patient had evidence of a severe vital sign abnormality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shortness of breath.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male with a past medical history significant for non-ischemic dilated cardiomyopathy with EF (ejection fraction) of 20%, who presented for evaluation in the ER due to dyspnea on exertion and at rest.  The patient was hemodynamically stable.  His oxygen saturation was 97%.  The ECG revealed sinus tachycardia, left atrial enlargement, and LVH (left ventricular hypertrophy) with secondary repolarization abnormalities.  Chest X-ray was unremarkable.  The cardiac troponins were negative.  Pro-BNP (pro-hormone B-type natriuretic peptide) was elevated at 2944, c/w CHF (congestive heart failure) exacerbation. 

The patient was seen in consultation by cardiology.  No ischemic work-up was planned.  Patient was diuresed with one dose of IV (intravenous) Lasix and switched to PO (by mouth) diuretic.  He was admitted for treatment of CHF.  Lisinopril was added to his regimen.  The patient was discharged home the next day with a plan for outpatient follow-up.

No, the proposed Inpatient Admission is not "medically necessary".

This patient presented for evaluation of exacerbation of chronic CHF (congestive heart failure) due to medication non-adherence.  The patient had a known diagnosis of non-ischemic cardiomyopathy.  No ischemic work-up was planned due to recent negative cardiac catheterization.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), malignant arrhythmia, hypoxemia or hemodynamic instability.  The patient was treated with IV Lasix with clinical improvement, and oral medications for CHF treatment were continued.  The patient was subsequently discharged in stable condition for outpatient follow-up. 

Given the presentation and course, as well as known diagnosis, an admission to an acute inpatient setting was not medically necessary, and the management of his acute exacerbation could have been performed in an observation setting with outpatient follow-up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute hepatitis

Treatment: Inpatient admission

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

This patient is a female with a past medical history significant for diabetes mellitus, hypothyroidism, liver disease, cholecystectomy, and post motor vehicle accident.  The patient presented to the Emergency Department (ED) with subjective complaints of right flank, right upper quadrant, and epigastric pain.  The patient complained of dark-colored urine.  The patient's pain was rated 10/10 and was noted to radiate to the back for two days with nausea and headache.  In the ED, the patient was placed nothing by mouth.  The patient's physical examination revealed tenderness in the right upper quadrant and epigastric area of the abdomen; there was no right/left costovertebral angle (CVA) tenderness, guarding, or rebound, and the patient had a negative Murphy's and McBurney's signs.

The patient had a segment of the right intrahepatic biliary tree that appeared dilated.  The patient was followed by a gastroenterologist during the hospital stay, and since no choledocholithiasis was present and there was a normal common bile duct, there was no indication for an endoscopic retrograde cholangiopancreatography (ERCP).  The patient's liver function tests trended downward and the patient was started on a diet.  The patient was discharged.

The patient presented with acute hepatitis, as indicated by laboratory studies including an ALT of 1125, AST of 597, alkaline phosphatase of 487 and total bilirubin was 2.1, with possible cholangitis, jaundice, and renal calculus.  The patient had multiple comorbidities as well as an underlying liver disease.  The potential causes for this patient's clinical presentation were serious enough to warrant admission to acute care and manage aggressively.  At the time of this patient's admission, there was a concern that a biliary decompression may be needed and causes for acute hepatitis needed to be investigated.  There was a high risk that this patient could have progressed to an acute liver failure as well.  Thus, inpatient admission and workup was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Foot Disorder/Plantar Fasciitis.
Treatment:  Orthotics.

The insurer denied the medical necessity of the custom orthotics.  The determination is overturned in whole.

This pediatric patient has been treated by a podiatrist for the past several years and has been diagnosed with Plantar fasciitis and pes planus.  The patient has severe arch pain due to his abnormal gait and flat feet.  The patient has undergone treatment in the past, which has helped, and he was set up for custom molded orthotics, which have helped in the past.  Patient has continued stretching exercises and wearing custom molded orthotics.  Patient presented to the provider's office for follow up, and it was noted that the patient's orthotics are too small.  The podiatrist initially requested a new pair of custom molded orthotics, and these were approved.  However, due to the Covid-19 pandemic, the patient was not able to be seen in a timely matter after the authorization was requested.  The request has since been denied.

Foot inserts are medically necessary for this patient.  This is based on the review of the medical records submitted, medical literature, and the review of the initial authorization.  The patient has a diagnosis of foot pain with plantar fasciitis and flat feet.  The patient has had previous treatment for foot pain that included foot inserts.  These inserts have helped  in activities of daily living to help reduce and control the pain.  The patient continues to perform stretching exercises and takes over-the-counter (OTC) medication, as necessary.  The foot inserts are medically necessary to continue to treat this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male with a past medical history significant for likely iron deficiency anemia and sleeve gastrectomy who presented to the emergency department because of low hemoglobin, which was identified on the outpatient blood work.
Reportedly, the patient was hospitalized approximately one month before the presentation after he sustained a syncopal episode and was also found to be anemic. 
At the time of the initial evaluation, the patient denied chest pain, palpitations, abdominal pain, hematochezia, melena, nausea, vomiting, decreased oral intake, diarrhea, syncope, lightheadedness, blurry vision. In addition, the patient denied fever, chills, shortness of breath, cough, wheezing, lower extremity tenderness, swelling, or erythema. In the emergency department, the patient received one unit of packed red blood cells as well as Protonix.

The patient had a normal head, eyes, ears, nose, throat (HEENT) exam. The cardiac exam was normal. Lungs were clear to auscultation bilaterally. The abdominal exam was unremarkable. The patient had good peripheral pulses in the lower extremities. The neuro exam was unremarkable.

The patient was admitted to the hospital with likely iron deficiency anemia. The admitting physician decided to rule out gastrointestinal bleeding. A workup of anemia was initiated. In the hospital, the patient continued to receive treatment with intravenous proton pump inhibitors. His hemoglobin remained stable, therefore the patient was discharged home in satisfactory clinical condition.

The subject under review is the medical necessity for the inpatient stay.

Even though the patient presented to the hospital with significant anemia, he had no signs of acute gastrointestinal bleeding or symptoms associated with anemia. Furthermore, in the hospital, the patient did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Therefore, neither the severity of the patient's condition nor the complexity of services provided justified admission at the acute inpatient level of care.

Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cerebral dysfunction.
Treatment:  Inpatient admission.

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

This patient is a male with a past medical history of congestive heart failure, coronary artery disease with stenting, hypertension, chronic renal disease, seizures, diabetes, paroxysmal atrial fibrillation on Xarelto, depression, substance abuse, and a cerebrovascular accident with residual left-sided facial droop and left-sided hemiparesis.  The patient presented to the Emergency Department (ED) with subjective complaints of "I just got weak".  The patient had subjective complaints of weakness and muscle aches.  The patient was brought in by the Emergency Medical Services (EMS).  The patient's blood pressure was 177/100.  The patient's pain was rated 6/10 and was sudden in onset. 

The patient's Glasgow Coma Scale was 15.  The patient was able to follow simple commands.  The patient complained of headaches.  The patient's National Institutes of Health Stroke Scale Score (NIHSS) was 5.  The patient's chest x-ray revealed increased interstitial markings with right infrahilar density, which may have been secondary to atelectasis, infiltrate, or vascular crowding.  The patient was seen by the neurologist.  The patient was admitted to the Stroke unit for continuous telemetry monitoring.  The patient underwent imaging studies, which revealed no acute intracranial abnormalities.  The patient's angiogram of the head was unremarkable.  The patient underwent an electroencephalogram (EEG), which revealed an abnormal recording because of the diffuse slowing in the background activity secondary to cerebral dysfunction.  The patient was seen by cardiology.  Once the patient was cleared, he was discharged home.  The patient was to follow-up with his primary care physician, per the discharge documentation.

Based on the review of the medical chart, the patient was admitted to the hospital for diffuse weakness with aching.  The patient underwent imaging study of the brain, which showed no acute ischemic changes and an electroencephalogram (EEG) that showed diffuse slowing due to his preexisting cerebral dysfunction; EEG revealed no ictal changes.  The patient was evaluated by both cardiology and neurology services.  Diagnostic workup, including imaging studies and EEG, along with specialty consultations, could have been performed in the Emergency Department setting or on an observation level of care.  Based on the review of the clinical guidelines, the care that this patient received did not warrant inpatient admission.

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

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

Diagnosis: Community acquired pneumonia

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

This patient is a male who presented to emergency department (ED with history of fevers, shortness of breath and cough of 1 week duration. The patient also complained of chills, headache, weakness, and decreased oral intake. The patient had seen his physician a few days prior who prescribed Amoxicillin. The patient did not get relief with antibiotics and the patient presented to the ED.

Vital Signs at presentation temperature 98.8 F, heart rate 93, respiratory rate 20, blood pressure 116/76 mm Hg, and oxygen (O2) saturations 100%.The patient was in no respiratory distress. She was alert and oriented. The lung exam revealed crackles at bases. White blood cell count (WBC) was 7.2 K, Na+ 130 BUN/Cr 14/0.8, Hb 11.4, mild elevation in LFT's. Chest x-ray revealed right lower lobe infiltrate.

The patient was admitted with a diagnosis of community acquired pneumonia. The patient was treated with intravenous (IV) Rocephin and oral Azithromycin. Diagnostic studies were sent. 

As per the history and physical done the patient was in no acute distress.  Temperature 98.8, heart rate 102, respiratory rate 16, blood pressure 122/81, and oxygen saturations were 100%. Lungs were described as clear and cardiovascular systems were normal. Abdomen was soft and the neurological exam was non-focal. WBC 6.2 K Na+ 133 BUN/ Creatinine within normal limits (WNL). LFT's were trending lower.  T Bili WNL The patient was continued on the same antibiotics. The patient remained stable after admission and was discharged home the next day.

This patient did not need acute hospitalization. He was afebrile and hemodynamically stable at presentation.  Oxygen saturations were never lower than 90%. WBC was normal Na+ mildly decreased but improved to 133 after hydration in ED. BUN/ Cr Normal. The patient was awake and alert. The patient was able to tolerate oral intake. The patient's CURB 65 score was Zero. This patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission, was tolerating oral intake, and was discharged the next day on oral antibiotics. This patient was stable to have been placed in Observation status and once remained stable overnight he could have been discharged home on oral antibiotics which included coverage for atypical organisms. The patient had received only amoxicillin (which does not cover atypical organisms) as an outpatient. The patient could have been followed up closely in the outpatient setting.

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

Based on the above, the medical necessity for the hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute exacerbation of asthma 
Treatment: Inpatient admission 

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

This patient is a male who has history of asthma who presented to the Emergency Department (ED) with complaints of shortness of breath, cough and wheezing for 2 days duration. The patient complained of recent upper respiratory tract infection symptoms and had been seen in the ED the day prior and had been treated with bronchodilators. The patient was discharged home on oral steroids. The patient felt tightness in chest again and returned to the ED. The patient received MgSo4 and Nebs and Decadron by EMS on route to the ED. At presentation to the ED, the patient's vital signs showed: temperature 98.6 F, heart rate 99, respiratory rate 18, blood pressure 136/78, and oxygen (O2) saturation of 97 % on room air. The patient's peak expiratory flow (PEF) was 300L/min, and his best PEF was 500L/min. The patient was in no acute distress. The patient's lung exam revealed bilateral wheezing but the patient was alert and oriented. The patient's cardiovascular and abdominal exams were unremarkable. The patient's white blood cell (WBC) count was elevated at 14.5 K but the patient was on oral steroids, which would have contributed to his leukocytosis. The patient's chest x-ray revealed (CXR) no acute infiltrate. 

The patient was admitted to the hospital for acute exacerbation of asthma. The patient was treated with bronchodilators, Singulair, and oral Prednisone. The patient remained stable after admission, the patient's PEF improved to 400L/min and was discharged home on bronchodilators and oral steroids, with close follow up in outpatient setting. As per the admitting H&P note the patient's vitals were: Temperature 98.2, Blood Pressure 151/81, Heart Rate 101, Respiratory Rate 18, and Oxygen Saturation of 100% on room air. The patient was noted to appear comfortable, speaking full sentences without signs of respiratory distress. 

Based on the review of the medical record, the patient did not need inpatient admission. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was afebrile and hemodynamically stable. The patient had no hypoxia, and no clinical signs of pneumonia, pleural effusion or pneumothorax.  The patient was tolerating oral intake, and the patient's peak expiratory flow was stable around 300L/min. The patient was stable to be discharged after a period in observation on oral steroids, bronchodilators and other oral medications. 

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

Based on the above, the medical necessity for inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary 
Surgical Services  (All) 

Diagnosis: Breast Pain 
Treatment: Removal of Breast Implants 

The insurer denied the removal of breast implants. The health plan's determination is upheld. 

This female had previously undergone bilateral cosmetic breast augmentation. She complained of breast pain, upper respiratory issues, fatigue, migraines, abdominal pain and hypothyroidism. She had pain with arm movement and redness and itchiness of her breasts. Per the patient appeal letter, specialist evaluation did not improve her condition. Her surgeon performed bilateral breast implant removals and capsulectomies to treat her condition. 

The Breast implant removals and capsulectomies were not medically necessary. The peer studies do no support removal of this patient's implants and capsulectomies to prevent or treat a systemic inflammatory condition. Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer. Capsular contracture is a benign condition. Although contractures and breast implants can be painful, they do not pose a health risk or danger. Surgery will make the patient more comfortable and will improve the appearance of her breasts, but surgery was not necessary to prevent a disease or illness or to treat a functional problem. 

Therefore, the removal of breast implants was not medically necessary.