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

Diagnosis: Hand Injury

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is a female with a history of asthma and bipolar disorder. She presented to the emergency room (ER) with complaints of left pinky pain. She had a tendon repair injury. The patient was admitted for treatment. She underwent left hand scar revision, tenolysis, neurolysis, and release of intrinsic muscles. The patient tolerated the procedure well. She was able to tolerate a regular diet, void independently, have bowel movements, and ambulate. The patient was discharged. 

The medical record demonstrates the patient underwent a noncomplicated hand procedure. It was not complex nor extensive. (Debridement, capsulotomy, release of intrinsics).  The operative report included a 30-minute procedure with 15 cc (cubic centimeter) blood loss. The hypotensive episode was noted in ASU (Ambulatory Surgical Unit) but corrected without residua. The anesthesia record notes discharge to home with Tylenol for pain. All subsequent measurements of blood pressure were within normal range. 

The records show no evidence of fever nor bleeding. There were no problems with her wound. She was able to tolerate oral pain medications. She did not require treatment for her underlying psychiatric history. She did not require testing nor management for other medical conditions. 

These findings do not substantiate necessity for the inpatient admission. The services could be provided at the observation level. 

There were no extenuating circumstances to require the admission and service. 

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

The inpatient admission is not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male, who presented to the hospital for scheduled cardiac catheterization for complaints of exertional chest pain. His medical history was remarkable for diabetes. His coronary artery calcium score was 1171; coronary computed tomography (CT) angiography suggested a hemodynamically significant stenosis in the left anterior descending coronary artery (LAD). Coronary angiography showed significant proximal and mid-LAD stenosis. The right coronary artery was diffusely diseased. Two drug-eluting stents were implanted in the LAD. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. He remained stable overnight and was discharged the following day. 

At issue is the Inpatient Stay for medical necessity. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. 
While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. Current guidelines from the Society for Cardiovascular Angiography and Interventions recommend inpatient admission in patients with acute ST segment elevation and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient had stents placed in the same vessel and his procedures were uncomplicated and did not require an inpatient level of care. 
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of non-ischemic cardiomyopathy (CMP) - ejection fraction (EF) 20% (percent), non-obstructive coronary artery disease (CAD), history of Coronavirus. The patient presented to the emergency department (ED) with complaints of fever and cough for 2 days.  Vital signs(V/S) at presentation were Temperature 100.1 Fahrenheit Blood Pressure 163/107 mm/Hg (millimeters of mercury), Respiratory Rate 18 Heart Rate 98 and Oxygen (O2) saturations 99. The patient was in no acute distress (NAD) appearing non-toxic.  Lungs were clear. The patient was coughing on exam. Abdomen was soft and non-tender. Cardiovascular system (CVS) was normal and the neuro exam was non focal. White blood cell count (WBC) was 5.5, electrolytes within normal limits (WNL)
Blood urea nitrogen (BUN/ Creatinine WNL, venous blood gas (VBG) 7.44 / 37 / 40. Chest x-rays revealed (CXR). No acute Infiltrates. Computed tomography (CT) Chest No acute changes.

The patient was admitted to hospital with fever/ cough rule out (R/O) pneumonia (PNA) Viral infection. History of congestive heart failure (CHF). Some weight gain noted.   
The patient was treated with intravenous (IV) antibiotics. Given low dose Lasix as some weight gain noted even though the patient did not have any signs of overt failure.  
Tests for Strep and Legionella were negative.  The patient remained stable after admission. No signs of acute infection. He was treated empirically with antibiotics. The patient did not have a myocardial infarction (MI).  As per history and physical (H&P) Temperature 99.8, Heart Rate 85, Respiration Rate 18, Blood Pressure 63/98, and O2 saturations 98%. Lungs were clear.  The patient remained afebrile and hemodynamically (HD) stable after admission. Was tolerating oral (PO). He was stable for discharge on oral antibiotics if needed and PO (oral) maintenance medications including Lasix.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission. No MI, no PNA. He was hemodynamically stable. Tolerating PO. This patient remained stable after admission and was stable for discharge on PO meds once Sepsis/ Severe PNA/ MI etc. was ruled out. Pneumonia if at all presents was very mild with CURB 65 (confusion, blood urea nitrogen, respiratory rate, blood pressure >65) of Zero.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Positional Vertigo

Treatment: inpatient admission

The insurer denied coverage for acute inpatient admission.

The denial is upheld.

The patient is a male that presented to the Emergency Department (ED) complaining of dizziness for several days and weakness. Upon arrival to the ED, vital signs were stable with blood pressure (BP) 162/106 and heart rate (HR) 80. Physical examination did not reveal any abnormalities. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm with nonspecific T wave abnormalities in the inferolateral leads.

Serum blood testing revealed no significant abnormality. High sensitivity troponin was not elevated (4.8ng/L (nanogram per liter)). COVID (coronavirus) antigen testing was positive. The patient was admitted to the hospital to treat lightheadedness and hypertension. Computed tomography (CT) scan of the head revealed no abnormality. The patient was treated with meclizine and antihypertensive therapies and discharged.  According to the European Society of Cardiology syncope guidelines, this patient was low risk for future morbidity and mortality (1). In a study of individuals presenting to the emergency room with dizziness, near syncope and syncope, patients that were low risk for cardiac events (no acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing (2). This patient was low risk and was diagnosed with positional vertigo. He presented with dizziness and no significant cardiac findings were noted on serum blood testing or EKG. Head CT revealed no abnormality. The patient was diagnosed with vertigo and treated with meclizine. He was discharged two days after presentation. 

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

The insurer's denial of coverage for acute inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Gastroparesis

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is overturned.

This case involves a female diagnosed with glycogen storage disease type 1 B, irritable bowel syndrome/visceral hyperalgesia, gastroparesis, diabetes (on insulin pump), Crohn's disease, depression, and chronic back pain.

The patient was admitted for a gastrointestinal procedure. The patient has a history of a complicated course of Clostridium (C.) difficile and Heliobacter (H.) pylori infection that resulted in neuropathy and gastroparesis. The patient continued to have chronic abdominal pain rated 10 out of 10. The patient was unable to tolerate food by mouth and reported nausea and vomiting that happened at night. There were also reports of reflux, abdominal distention and sweats. The patient utilized a percutaneous endoscopic gastrostomy (PEG) tube for tube feedings. The examination documented normal bowel sounds. The abdomen was distended. The patient underwent a gastric peroral endoscopic myotomy (G-POEM) procedure. There were reports of improvement in pain along with continued nausea. The patient was then discharged.

POEM is a recognized procedure by the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE) societies as an effective procedure for severe achalasia and gastroparesis. This is a complex procedure that requires at least an overnight stay. Subsequent management involves assessing whether there is a post-operative leak with a radiological assessment. Monitoring blood sugars and fluid resuscitation are indicated.

This patient has severe gastroparesis and was previously treated with PEG placement. Her complaints were refractory to this technique. This patient met the indication for POEM and her management was consistent with community standards.

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

The insurer's denial of coverage for the hospital is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves an adult female with a history of asthma, high cholesterol, obesity, and osteoarthritis. The patient presented to the hospital for scheduled total left hip replacement. The patient received routine perioperative intravenous antibiotics and Ecotrin. She tolerated physical therapy well and met all the necessary goals for discharge. The patient's pain was adequately controlled.  Her hospital course was uneventful. She was discharged.

Per the MCG (Milliman Care Guidelines) Guidelines, an ambulatory procedure may be appropriate in selected patients undergoing a primary unilateral elective procedure when they do not have unstable comorbidities that would significantly increase the risk and would require prolonged postoperative monitoring. Inpatient treatment may be indicated for patient undergoing nonelective, bilateral revision procedures, and for those with comorbidities that require more prolonged postoperative treatment or monitoring. It is recommended for patients without sufficient outpatient care and support to allow early outpatient recovery. Observation services are considered medically necessary for an individual who requires short-term monitoring that is not expected to exceed 24 hours but would generally be no longer than 48 hours.

In this case, the patient presented an elective total left hip replacement. The patient presented to the hospital for a left total hip replacement. During the admission, the patient was given prophylactic antibiotics for 24 hours. The patient was in the operating room for almost 2 hours. A wound VAC (vacuum-assisted closure) had been placed. The patient was placed on telemetry postoperatively.  Pain medications were needed. The patient participated in physical therapy. However, the patient's care could have been completed at an observation level of care. The patient did not have unstable comorbidities, hemodynamic instability, or required treatment or monitoring that was expected to exceed 24 hours. Thus, the inpatient admission was not medically necessary.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoarthritis, coronary artery disease (CAD), hypothyroidism, and hyperlipidemia.
Treatment: Personal care aide (PCA) level 2: 10 hours per day- 6 days per week- for a total of 60 hours per week.

The insurer denied coverage for personal care aide (PCA) level 2: 10 hours per day- 6 days per week- for a total of 60 hours per week.
The denial is overturned.

This elderly female has several medical conditions contributing to functional decline for daily activities. The patient lives alone. As per uniform assessment system (UAS), she has no informal caregivers to provide assistance on a regular basis (family is supportive but they do not live near patient). The patient relies on personal care aide (PCA) services for help with activities of daily living (ADL) and instrumental (I)ADLs. She is receiving PCA 9 hours per day, 5 days per week. 

The patient has chronic pain. The UAS include reports of knee, shoulder, and back pain/stiffness. The UAS indicates the patient has osteoarthritis. The hospital progress notes indicate patient has history of bilateral total knee arthroplasty (TKA) (dates not noted). The need for bilateral knee replacement indicates longstanding and advanced arthritis. It is not clear to what extent the patient's knee symptoms limit her activities, but the UAS indicates she needs extensive assistance for walking, transfers (difficulty moving from sitting to standing) and lower body dressing. The ability to perform these ADLs is often limited by pain and stiffness in the knees. The patient's back pain and stiffness also can affect mobility, as well as activities that requires bending (e.g., bathing, lower body dressing, various household tasks).

The need to use the toilet and episodes of incontinence occur at various unplanned times throughout the day. The patient has no informal caregivers; and so, when the PCA is not present, the patient must perform all toileting related tasks unassisted which places her at risk for adverse consequences as noted above. Having a caregiver present for most of the day (from morning until patient gets ready for bed) can help prevent toileting related adverse events, e.g., falls/injuries, skin damage, patient discomfort.

The UAS reports patient needs extensive (weight-bearing) assistance for walking/locomotion and transfers. 

The insurer's adverse determination letter indicates a request for PCA 10 hours per day, 6 days per week, total of 60 hours per week. Current services are 9 hours per day 5 days per week. Regarding allocation of hours, if the family has other plans for assistance one day per week, then PCA hours can be allocated over 6 days, 10 hours per day. If there is no plan for assistance for the 7th day, then the patient and family can help determine the best use of the 60 PCA hours allocated throughout the entire week. 

The insurer's denial of coverage for personal care aide (PCA) level 2: 10 hours per day - 6 days per week- for a total of 60 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Pyelonephritis

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld.

This is a female with past medical history of Ehlers-Danlos syndrome, Von Willebrand disease, Chiari malformation and pleurisy. The patient had been recently diagnosed at another hospital's emergency department with acute pyelonephritis and given Levaquin to take as outpatient therapy. The patient subsequently presented to emergency department with complaint of continued right sided abdominal pain, fever, and decreased oral intake. Pain was noted as 8/10, exam was positive for RUQ (right upper quadrant) abdominal tenderness and right CVAT (costovertebral angle tenderness). Urinalysis was negative (-) for LE (leukocyte esterase), nitrites, bacteria. The patient was admitted for acute pyelonephritis and started on intravenous fluids, intravenous antibiotics, and parenteral pain medications. The patient's pain and other symptoms improved, and she was cleared for hospital discharge on an oral antibiotic and plans for outpatient follow up. 

This patient presented to emergency department with complaint of abdominal pain, dry cough, poor oral intake, no bowel movement for last 5 days. The patient had no fever in emergency department and urinalysis was unremarkable. Per MCG (Milliman Care Guidelines) Health (25th) urinary tract infection, the patient fails to meet clinical indications for admission to inpatient care, but does appear to meet guidelines for observation care:

1) Pain (flank or abdominal) not adequately controlled with initial emergency department treatment. 2) Response to, or ability to tolerate outpatient treatment regimen. 

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

The inpatient hospital stay is not considered medically necessary for this patient.

The insurer's denial of coverage for inpatient hospital stay is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: HIV (human immunodeficiency virus) infection, HBV (hepatitis B virus) coinfection
Treatment: Formulary exception for Stribild Tablet 150-150-200-300 mg
The insurer denied the Formulary exception for Stribild Tablet 150-150-200-300 mg
The denial is upheld.

The patient is a male with history of HIV (human immunodeficiency virus) infection, HBV (hepatitis B virus) coinfection. The request for Stribild Tablet 150-150-200-300 mg (milligrams) is under review.

The patient has been on the current regimen for several years, tolerating the current regimen and being controlled by it. There is no history of hypercholesterolemia, bone or kidney disease. The patient's physician would like to continue the Stribild, while the health plan would like an alternative that is on the formulary to be tried.

No, the health plan should not cover the Formulary exception for Stribild Tablet.
The medication requested, Stribild, is made up of 4 medications: tenofovir disoproxil fumarate, emtricitibine, elvitegravir, and cobistatin. On the formulary is a medication by the name of Genvoya, which is made of 4 medications: tenofovir alafenamide, emtricitibine, elvitegravir, and cobistatin. Thus, the difference between the two medications is in only one of the 4 components. What is more is that the difference between tenofovir disoproxil fumarate and  tenofovir alafenamide is minimal, and according to studies, the tenofovir alafenamide has a number of advantages when given long term (less renal dysfunction and fewer bone disorders) (1). The patient's physician has not given any reasons why tenofovir disoproxil fumarate would be superior to tenofovir alafenamide in this case. Thus, given the information provided, it is expected that the formulary alternative would be superior to the regimen requested.

Therefore, given then above, the health plan should not cover the Formulary exception for Stribild Tablet.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II subdivision left malocclusion with moderate crowding.
Treatment: Braces and office visits.

The insurer denied braces and office visits.
The determination is overturned.

The patient has a Class II subdivision left malocclusion with moderate crowding. Tooth number 10 is in anterior crossbite. He is treatment planned for 24-30 months of orthodontics to correct the crowding and crossbite. At issue is the medical necessity of braces and office visits.

The requested treatment is medically necessary.  Tooth 10 is in crossbite with teeth 22 and 23. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) These problems are much more time consuming to correct than the patient's current orthodontic problem. Tooth number 10 is at great risk of wear and damage. Therefore, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

The patient presented to the emergency department (ED) complaining of dyspnea, a cough, orthopnea and pleuritic chest pain. His medical history was remarkable for diabetes, hypertension, chronic kidney disease, congestive heart failure, coronary artery disease, peripheral vascular disease and hyperlipidemia. In the ED, his blood pressure was 140/63 millimeters of mercury (mmHg) with a heart rate of 63 beats/minute. His respiratory rate was 16/minute with a room air oxygen saturation of 95%. He had pulmonary rales on physical exam. A chest x-ray showed moderate pulmonary edema. An electrocardiogram showed sinus rhythm without acute changes. His serum troponin level was minimally elevated without significant change when remeasured. His brain (or B-type) natriuretic peptide (BNP) level was 1246 picograms per milliliter (pg/ml). His serum creatinine level was 2.14 milligrams per deciliter (mg/dl) (his baseline level was not documented). His hemoglobin level was 9.2 grams per deciliter (gm/dl). The patient was treated with intravenous furosemide and aspirin. He was admitted to the hospital for management of decompensated heart failure. Later in the day he denied dyspnea and orthopnea; his cough was improved but not resolved. The patient had no complaints. His serum creatinine level was 2.45 mg/dl. His furosemide was held. His creatinine level was 1.83 mg/dl. He was discharged. At issue is the medical necessity of an inpatient stay. 

Yes. Based on the documentation provided, an inpatient level of care was medically necessary. 

This patient was hospitalized with acute decompensated heart failure (ADHF). He had underlying chronic kidney disease (CKD) and developed an acute rise in his serum creatinine level during his hospitalization. In patients hospitalized with ADHF, preexisting CKD as well as acute kidney injury in the setting of CKD have been associated with an increased risk for in-hospital mortality, prolonged hospital stay and failure for renal function to return to baseline levels. This patient's anemia was an additional high risk feature. Anemia is associated with poor prognosis and prolonged hospital stay in patients hospitalized with ADHF. Given this patient's high risk features, careful and continuous monitoring with the ability to intervene emergently, if needed, was medically necessary. This warranted an inpatient level of care.