Persius/hicric huggingface dataset:
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Diabetes Mellitus Type 2.
Treatment: Freestyle Lite Glucose Monitor. 
The insurer denied the Freestyle Lite Glucose Monitor.
The determination is overturned.

The patient has diabetes mellitus type 2 complicated by neuropathy. He also has hypercalcemia. His physician has prescribed a Freestyle Lite meter to test his glucose levels. A letter from his doctor attests that patient has tried the formulary meter One Touch, with discrepant results in the past, causing the patient to miscalculate therapy. It appears that he also has tried Accu-Check meters in the past. At issue is the medical necessity of the Freestyle Lite Glucose Monitor.
The Freestyle Glucose monitor is medically necessary for this patient. He has tried the formulary meter and it has been ineffective with a 20 points discrepancy between the meter reading and glucose readings and it would not be in the best interest of the patient as he has had accurate results with the freestyle meter.
The American Diabetes Association (ADA) Standards of Medical Care in Diabetes (4) states: "Use of technology should be individualized based on a patient's needs, desires, skill level, and availability of devices" and "Providers should be aware of the differences in accuracy among glucose meters-only U.S. Food and Drug Administration-approved meters with proven accuracy should be used, with unexpired strips, purchased from a pharmacy or licensed distributor". In patients with diabetes mellitus type 2, self monitoring of blood glucose "may be helpful when altering diet, physical activity, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program".(4)
Even though studies show that the formulary One Touch meter overall accuracy comparable to the Freestyle Lite meter and they are both cleared by the Food and Drug Administration (FDA) (1,2), a variety of factors can affect glucose meter results, including operator technique, environmental exposure, and patient factors, such as medication, oxygen therapy, anemia, hypotension, and other disease states (3).
The patient's physician has submitted an attestation that patient has tried the required formulary product One Touch meters in the past, causing a discrepancy of 20 points between the meter reading and glucose reading.
Furthermore, the patient has neuropathy, which falls under the issue of patient dexterity . When a patient with diabetes has neuropathy, there is a compromise in dexterity due to a decrease in the ability to feel properly, therefore dexterity is compromised.
"Clinicians need to consider the variety of factors that can affect meter accuracy and interpret glucose meter results with regard to the potential for meter interference, questioning glucose meter results whenever the results do not match the clinical scenario"(3). In this case, the patient has had accurate results with the Freestyle meter and not with the One Touch meter. Using a meter that is not accurate for the patient will place the patient at risk for unsuspected hypoglycemia or hyperglycemia, in both cases compromising his health and life.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vaginal bleeding.
Treatment:  Inpatient admission.

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

The patient is a female who presented with chief complaint of heavy vaginal bleeding of five days duration.  The patient had a known diagnosis of adenomyosis.  She had two syncopal episodes, for which she was transfused with two units of packed red blood cells (PRBCs).  However, the patient kept feeling lightheaded and was brought to the emergency department (ED).

The patient's hematocrit was 21.  She was mildly tachycardic.  There was no evidence of active bleeding.  Because of a thickened endometrium, an endometrial biopsy was performed.  The patient was transfused with two units PRBCs.  She was discharged home later that day.

No, the proposed treatment, inpatient admission, was not medically necessary.

This patient was symptomatic for anemia.  This patient also fulfilled the transfusion guidelines for use of blood components: her hemoglobin was less than eight grams per deciliter (g/dl), and she was symptomatic, so transfusion was indicated.  However, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home).  So, the need for transfusion is not a reason for admission.

This patient could have been transfused in the ED.  She could have been monitored for a few hours in the ED, her complete blood count (CBC) repeated, and then discharged home with outpatient follow up.  Nothing was done in the hospital that could not have been done as an outpatient.  It is also noted that an endometrial biopsy does not require a hospital transfusion.

Based on all of the above, admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal Canal Stenosis, Spinal Disc Protrusion
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is upheld.
This is a male patient is a male who was admitted to the hospital with complaints of chronic pain located in his lower back and down the right leg. The patient reports that he has been experiencing it for several months and it had worsened over the last several days; he rated the pain as 7/10 in severity. The patient had a schedule for surgery. The patient noted a slight increase in difficulty urinating and had constipation due to medications. On exam, the patient had a positive straight leg raise test on the left and decreased sensation along L5 and swelling to the right leg and 4/5 weakness of the right leg with decreased sensation in the calf and dorsum of the foot. He was admitted to the hospital for pain management and surgical intervention.  The patient underwent an L4-5 right microdisectomy, medial facetectomy, foraminotomy and decompression of the nerve root without complications. The patient was medically stable and was discharged home in good condition.

Based on the review of the medical record, inpatient admission was not necessary for this patient according to the national policies including MCG Lumbar Discectomy, Foraminotomy or Laminotomy as they state the surgery is ambulatory or one day postoperative care. Inpatient is for non-elective or multilevel procedures or patients who need prolonged postoperative care. However, in this case, there is no evidence that this patient required every 4 hour intravenous medications or frequent neurological checks that warranted inpatient admission. The patient's care could have been managed at the observational level for pain control and imaging. The patient had no significant co-morbidities, did not require round-the-clock IV medications or steroids, and had no red-flag symptoms or severe findings on imaging to suggest cauda equina. Therefore, this patient's care could have been provided at a lower level of service.

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

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

Digestive System/Gastrointestinal.
Inpatient Stay.

Diagnosis :  Appendicitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history of asthma and presented to the emergency department on with a 12 hour history of abdominal pain which was described as constant severe sharp and localizing to the right lower quadrant. It was associated with nausea anorexia and non-bilious non-bloody vomiting. The exam was notable for tenderness to palpation in the right lower quadrant. A computed tomography (CT) scan demonstrated findings concerning for appendicitis therefore, the patient was admitted and placed on appropriate antibiotic therapy

An acute inpatient level of care was not medically necessary. The patient could have been safely and appropriately managed at a lower level of care. No evidence presented in the provided documentation or in the primary medical records indicates that the patient had complicated appendicitis, and the operative note clearly defines the perforation as a technical result of the operation, not as a pathophysiologic issue which may require an acute inpatient stay. There were no complications with the surgery and the patient had an uneventful postoperative course.
In one study authored by Aguayo et.al., in over 500 cases, approximately 28% (number [n]=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, probability [P]=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus, same day discharge is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. These data strongly suggest that for most patients with acute, nonperforated appendicitis who undergo an uncomplicated appendectomy, a lower level of care is appropriate since their needs are low acuity and the recovery is generally smooth and uneventful.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient with a history of nephrolithiiasis, hypothyroidism, anxiety, left knee traumatic arthroplasty, insomnia. He presented to the Emergency Department (ED) with complaints of right flank pain; a kidney stone was diagnosed prior to this ED arrival. A computed tomography (CT) scan was performed as an outpatient that revealed mild right hydronephrosis due to a 7mm obstructing stone proximal right ureter. The patient's initial labs showed creatinine 2.0. The patient was given intravenous (IV) fluids, IV morphine, Toradol. The patient was admitted to the hospital for urgent urologic intervention of a right stent placement. The patient received IV fluids and IV Ancef. The patient's repeat creatinine improved to 1.6. The patient was discharged home with outpatient patient follow up. 

Based on the review of the medical record and literature, there was no clinical indication for an inpatient level of care (LOC). 
Per the MCG Health (23rd) Renal Colic and Kidney Stone RRG, the patient fails to meet the clinical indications for admission to inpatient care, but does meet guidelines for observation care for acute change in kidney function, which was this patient's increase in creatinine level. 

Per MCG Health (23rd) Urologic Surgery or Procedure GRG, this patient is noted to have met the General Recovery Course discharge parameter within 24 hours after the procedure. As per the guideline, stent placement is usually preformed in the outpatient/ambulatory surgery setting. Thus, inpatient admission was not medically necessary for this patient.

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 admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psychiatric/alcohol withdrawal
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The denial was upheld.

The health plan's determination of medical necessity is upheld in whole. The review of the medical records demonstrated that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care. The patient presented to the hospital after a fall that resulted in a facial injury. A thorough evaluation that was performed during the short hospital stay did not demonstrate any evidence that the patient required any surgery or procedure for the treatment of  injury necessitating admission at the acute inpatient level of care. Another clinical problem was possible alcohol withdrawal. Considering the fact that the patient had alcohol withdrawal symptoms and came to the hospital with tremulousness, it was reasonable to admit the patient at a lower level of care for observation to ensure clinical stability and provide appropriate treatment.
However, during the hospital stay the patient developed only very mild alcohol withdrawal symptoms. It was clearly documented in the notes that the patient's CIWA score was between 1 and 9, which was consistent with very mild withdrawal. Patients with this degree of alcohol withdrawal usually do not require admission at the acute inpatient level of care.
At the time of the initial evaluation, the patient was noted to have slightly elevated troponin levels. However, the patient was completely asymptomatic and had no signs of acute myocardial infarction. Taking into consideration these facts, the admission for a lower level of care to rule out acute coronary syndrome and to obtain cardiology consultation was reasonable. The cardiologist recommended an echocardiogram. Even though the patient had a slightly elevated troponin level, it did not require any additional studies or treatments that would necessitate admission at the acute inpatient level of care.
the patient decided to leave the hospital against medical advice. At that time the symptoms of alcohol withdrawal resolved. It was indicated in the final note that the patient was not scoring on the CIWA score anymore. The elevated blood pressure, which was attributed to withdrawal symptoms, improved, and the leukocytosis, which was likely stress-induced, also resolved. At the time the patient left the hospital there were no new complaints, and in general, was in a stable clinical condition.
The patient sustained a facial injury, had alcohol withdrawal symptoms, elevated blood pressure, and leukocytosis. None of these medical problems were severe enough to justify the admission at the acute inpatient level of care. The patient's symptoms resolved quickly and did not require any additional procedures or treatments necessitating admission at the acute inpatient level of care. 
The admission at a lower level of care was warranted to rule out acute coronary syndrome and to ensure the improvement of withdrawal symptoms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: respiratory syncytial virus.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male child who presented with a cough. He was well until the evening prior to admission when he developed a dry cough. He was still eating well, but then he developed a fever to 100.2 F. He also developed a rash on his face and his chest and neck. The prior week he was exposed to his grandfather who had a cold.
In the emergency department, he was found to have a temperature of 37.5 C and a heart rate of 161 beats per minute (bpm). A urine and blood culture were sent, and he was found to have respiratory syncytial virus (RSV) infection. Due to his young age and the presence of RSV infection, he was admitted for further care.

The inpatient hospital admission was medically necessary.
This is a very young child who presented with a history of fever and RSV infection. His very young age alone is a risk factor for severe or complicated disease with RSV infection, including apnea. In addition, this child had a history of fever at home and was also at high risk for serious bacterial infection. Even well appearing febrile neonates (28 days of age or younger) can become ill very quickly and require close monitoring with additional treatments as needed. Therefore, an inpatient hospital admission was appropriate to provide continuous monitoring for apnea as well as sepsis, and to provide additional treatments as needed.
The decision making at the time of admission for this patient was consistent with his very young age, a history of fever and presence of RSV infection, and the need for continuous monitoring with prompt treatment as needed for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Physical impairment.
Treatment:  Continued skilled inpatient rehabilitation and nursing.

The insurer denied coverage for continued skilled inpatient rehabilitation and nursing.  The denial is upheld. 

This is a female patient with multiple chronic medical problems including asthma, venous stasis with leg ulcers and swelling.  She was admitted to skilled inpatient rehabilitation and nursing and received physical and occupational therapy.  Under review is the medical necessity for continued skilled inpatient rehabilitation and nursing as of week 7 of admission. 
  
The clinical records initially demonstrated a level of physical impairment that supported the medical necessity for subacute rehabilitation services.  As of week 7 of admission, the treatment notes document a plateau in functional progress.  At that time, the patient was independently transferring and ambulating with a rolling walker (supervision).  The patient was discharged from physical therapy.  The physical therapist noted that the patient was currently plateaued and was at her functional baseline at that time.  She was also discharged from occupational therapy with a similar plateau in functional progress.  

There were no specific acute medical problems or complicated nursing issues preventing the patient's safe discharge to a lower level care effective as of week 7 of admission.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued skilled inpatient rehabilitation and nursing as of week 7 of admission was no longer medically necessary.

Based on the above, the medical necessity for continued skilled inpatient rehabilitation and nursing is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis Bilateral Lower Extremities
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. 
The health plan's determination is overturned.

The patient is a  female with a past medical history of obesity, peripheral artery disease (PAD) with bilateral stents, atrial fibrillation, and hypertension (HTN), who came to the Emergency Department  with fever, chills and worsening redness, pain and warmth of bilateral lower extremities for 3 days.
Initial vital signs were a blood pressure (BP) of 96/62 millimeters of mercury (mmHg) to 139/72 mmHg, a respiratory rate (RR) of 22/minute, a heart rate (HR) pf 86 to 127 beats per minute (bpm), a temperature of 100.6F. to 101.8F. and an oxygen saturation of 92-98 % on ambient air. On admission, the patient had a hemoglobin level of 14.1 g/dl (grams per decilitre), a sodium of 138, a potassium of 4.0, a glucose of 137, a blood urea nitrogen (BUN) of 18, a creatinine of 1.1, a white blood cell count (WBC) of 12.4 K (thousand), and a lactic acid (LA) of 2.6. On physical exam, the patient had erythema and swelling of "Bilateral lower extremity edema up to the knees, streaking up the medial thighs bilaterally, tender to palpation, no open wounds." The patient had no evidence of deep vein thrombosis (DVT) on venous doppler studies.
After treatment with intravenous (IV) hydration and antibiotics, the patient responded well and clinically improved. The patient was discharged in stable condition.

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

Yes, patient's inpatient stay was medically necessary. The treating physician made the determination that inpatient admission was necessary and most beneficial for the treatment of the patient's sepsis due to lower extremity cellulitis. There is likelihood and expectation for inpatient stay for 2 midnights or more, for the following reasons:
1) The patient met severe sepsis criteria: temperature, HR, RR, WBC, source of infection present, elevated LA.
2) Inpatient hospitalization was indicated due to need for intense monitoring of infection progression.
3) Elevated lactic acid and systemic inflammatory response syndrome (SIRS) picture were indications to suspect bacteremia.
4) The patient's significant history of peripheral vascular disease would place the patient at high risk for necrotizing soft tissue infection.
5) Cellulitis in obese patients is associated with increased rates of treatment failure compared to those with normal body mass index (BMI).
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She presented to the emergency room for an abscess on her back. She has a past medical history of hypertension and morbid obesity.

In the emergency room, the patient's vital signs were stable, and she was afebrile. Her exam was notable for a 15 cm (centimeter)-wide actively drainage abscess with 10/10 pain. Her WBC (white blood count) was 11.98.  She had an abscess in the same area three months prior that was incised by her primary physician. At this occurrence, she noticed it had "popped" and drained.

The patient was admitted for observation, IV (intravenous) antibiotics, and an evaluation by the wound team. An infectious disease doctor noted her to have only a 2x.5 cm (centimeter) abscess without drainage. She was recommended to continue on oral antibiotics, obtain a surgical consultation, use warm compresses, and discharge home.

No, the Inpatient admission was not medically necessary.

The patient did not have fevers, identified organisms, or noted failure of outpatient management. The patient did not have other comorbidities, such as diabetes, that would require inpatient admission. No surgery was performed. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Uvular edema and pain.
Treatment:  Inpatient admission.

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

The patient is a male.  He presented to the ED (emergency department) with uvular edema and pain after having undergone a tonsillectomy earlier in the day.

The patient's medical treatment included IV (intravenous) fluids, IV (intravenous) steroids and IV (intravenous) fentanyl.  The patient's vital signs were stable, and the patient was afebrile.  H/H (hemoglobin/hematocrit) was 12 and 38.

The patient was admitted to the hospital, and an endoscopy was performed by ENT (otolaryngology), where the enlarged uvula was noted, as well as copious secretions.  The patient was advanced with suspension pain medications, and the diet was advanced.  The patient was discharged.

No, the Inpatient admission was not medically necessary.

All records were reviewed.  The patient was reported to be in no acute respiratory distress when he presented, but he did have a muffled voice and felt like he was occasionally choking.  There was no stridor noted or intercostal retractions.  Physical exam did not reveal any difficulty breathing.  The patient improved symptomatically with the IV (intravenous) steroids, and the swelling improved, as well.  The diet was advanced.  There were no other complications that occurred, and the patient's clinical condition did not degrade during his stay.  Therefore, based on the information provided, the medical necessity of the inpatient admission cannot be confirmed, as the patient's care could have been provided at a lower level of care