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

Diagnosis:  Abdominal Pain
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a history of asthma and treated lymphoma in remission for six years and chemo-related kidney injury who was brought to the emergency department (ED) with nausea, vomiting, and abdominal pain. At triage, her temperature (T) was 36.9 degrees Celsius, heart rate (HR) 110, blood pressure (BP) 105/68, respiratory rate (RR) 18, and and oxygen saturation (O2 Sat) 99% on room air. The triage nurse documented that the patient had vomited once on the day of presentation, three times the day before and once the day before that, and was "able to tolerate Gatorade, water." She had been at a sleep-away camp. The ED physician's documentation confirmed this and added the patient had mid-epigastric pain on the day of presentation and had not stooled for four days. At camp, the day before, she had received a normal saline bolus once and blood testing that showed a normal complete blood count (CBC) (white blood cell count (WBC) 7.9) and basic metabolic panel (blood urea nitrogen (BUN) 18/ creatinine (Cr) 1.1). On exam, she had moist mucus membranes and capillary refill less than two seconds. In the ED, she had further laboratories that were unremarkable, normal abdominal and pelvic ultrasounds (stable sized dermoid cyst without torsion), and a normal urinalysis (UA). She did not want to take fluids orally due to nausea. She received two normal saline boluses in the ED and Zofran and was admitted to the pediatric floor. The admission history and physical (H&P) reiterated the above, and commented that she was nauseated when she took oral fluids, but did not have more vomiting in the ED. She received maintenance IV fluids while in the hospital, her nausea eased, and she was sent home. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.

The patient's past history of lymphoma was not relevant here. She did not have any respiratory symptoms and she was six years out from her lymphoma treatment. She did have a history of a chemo-related kidney injury, but her creatinine was stable, so the past history of kidney injury was not an issue here either. She presented with 2-3 days of nausea with vomiting and abdominal pain. Ultrasounds, labs, and serial, improving physical exams pointed away from a serious abdominal condition. She did not have fever, elevated C-reactive protein (CRP) or complete blood count (CBC). Her physical exam and laboratories did not suggest any degree of dehydration: she had moist mucus membranes, normal capillary refill, normal bicarbonate, normal BUN/Cr, and urine specific gravity of 1.014. Nonetheless, she received two normal saline boluses in the ED, so to the extent she was "dry" or approaching a mild dehydration, that situation was fully corrected in the ED. In addition, while she had nausea, she was able to take fluids without vomiting. There was no acute condition that required hospitalization following ED management. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:Right Thigh Mass
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

This is a patient with a complaint of a large right thigh mass. The patient had a history of hypertension. The right thigh mass had been present for one year with increasing size. The patient underwent a magnetic resonance imaging (MRI) scan of the right thigh  which confirmed a well differentiated liposarcoma. The records document that the patient underwent surgical removal of this tumor. The operation lasted 5 hours and recorded 300 milliliters (mL) of blood loss. The patient required close post-operative monitoring and had two Jackson-Pratt drains placed in the right thigh to revert hematoma formation after surgery. The patient was deemed stable for discharge to home. He had one drain left in place to be removed later and was maintained on oral Keflex for infection prevention. At issue in this case is the medical necessity of the inpatient stay.

The requested inpatient stay was medically necessary for this patient. The records document that this latent had an MRI documented liposarcoma of the right thigh. This required a surgical excision which was completed. This major operation lasted 5 hours and resulted in 300 mL of blood loss. The records also document that this patient required close post-operative monitoring and had two JP drains placed in the right thigh to prevent hematoma and seroma formation. The patient was maintained on antibiotics while the drains were in place. Due to persistent drain output, the patient was maintained on oral Keflex and was sent home with one drain in place. Based on the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature, the inpatient stay for this patient was medically necessary. The current peer-reviewed orthopedic literature, including articles published by Johnson and colleagues the Journal of the American Academy of Orthopedic Surgeons and by Thway and associates confirmed that the care rendered in this case was appropriate and consistent with the current standard of care. Based on the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature, the inpatient stay for this patient was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient who walked in and presented with alcoholic intoxication and
atypical chest pain described as "pain to side", and described by treating physicians as bilateral flank pain. He also had a headache and abdominal pain. The patient had a history of cardiomyopathy with a wearable cardiac defibrillator that he was not wearing.

Exam unremarkable with normal vital signs and normal oxygen saturation. He had troponins of 0.04 and 0.05. Electrocardiogram (EKG) was abnormal but unchanged. Admission diagnosis was muscular skeletal chest pain. Cardiology consultation was obtained. Stress test was negative for ischemia. The patient's chest pain resolved. The patient left against medical advice.

No, inpatient level of care was not medically necessary.

The patient had atypical pain for several days that resolved without intervention. There was no evidence of acute coronary syndrome (ACS) on EKG. This hospital's level for normal troponin is 0.03; clinically, in patients with coronary artery bypass grafting (ABG), and history of severe cardiomyopathy, serial troponins of 0.04 and 0.05 are not considered clinically significant. The approach of the treating physicians was not that this patient had ACS. Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG). The patient's stress test was negative. He was always
hemodynamically stable.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. The letter of appeal was carefully considered but it offered no evidence to support inpatient level
of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. It would not be considered "gross negligence" to observe this patient, perform the same tests, and discharge upon results. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. He did not have angina as assessed by the treating team.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High blood glucose 
Treatment: Inpatient admission 

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

This is a male with Alzheimer's disease who presented to the emergency department for a fasting glucose of 536 milligrams per deciliter (mg/dL). The patient's glucose was 301 mg/dL in triage. No known prior history of diabetes. The patient had a headache. Urine glucose was greater than (>) 1000, serum glucose was 394 mg/dL, bicarbonate (HCO3) was 27, pH was 7.37, and beta-hydroxybutyrate was 0.4. Prior glycosylated hemoglobin (A1C) was greater than (>)14%. He had a dry mouth, polyuria, and polydipsia. He was given intravenous fluid and started on Levemir and lispro insulin. He and his wife received diabetes education. He was discharged home. 

No, the proposed inpatient admission was not medically necessary. 

This patient presented with hyperglycemia and dehydration in the setting of newly diagnosed type II diabetes. The patient was hemodynamically stable. He did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. He had mild dehydration that responded to intravenous fluids. The documentation does not support that he failed management at a lower level of care. He was started on subcutaneous insulin, received diabetes education, and was discharged the following day. Therefore, no, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting, shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. The patient presented to the emergency department of the facility filing the appeal with the complaints of shortness of breath and abdominal pain. The patient was discharged less than 24 hours later.  A CT scan showed distention and fecalization of the distal ileum with a concern for an obstruction.  An NGT (nasogastric tube) was placed without significant drainage. The symptoms resolved and the surgical consult felt the findings were more consistent with gastritis. The surgical consult did not agree with a concern for small bowel obstruction. 

No, the Inpatient admission is not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  The symptoms all resolved within 24 hours. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient with a past medical history of hypertension, hyperlipidemia, diabetes mellitus, non-alcoholic fatty liver disease, sleep apnea, and morbid obesity.  He presented to the ER with intermittent dull chest pain described as tightness or pressure, and associated diaphoresis, shortness of breath and feeling lightheaded.  Vital signs were stable. He reported he had a coronary computed tomography (CT) done 3 weeks prior which was unremarkable, with a calcium score of zero and no stenosis appreciated.  Troponin high sensitivity testing was 23, with a repeat level of 17.  An electrocardiogram (EKG) showed normal sinus rhythm with no ST elevations or depressions, with non-specific T-wave abnormalities in inferior leads. Chest radiography was normal.  The patient was seen by Cardiology and Endocrinology.  A 3rd troponin T level was 22, indicating no acute myocardial infarction.  No pulmonary embolism was noted on CT scan.  The patient had episodes of atypical chest pain during his stay treated with Tylenol and Maalox.  Protonix was started empirically for gastroesophageal reflux disease (GERD).   The patient's symptoms resolved and there were no acute events on telemetry.  He was discharged home..

The patient presented with a history of chest pain. Given his comorbidities, his presentation was initially concerning for cardiac etiology. He underwent an appropriate initial evaluation in the emergency department, the results of which were unremarkable. His evaluation included the findings of normal hemodynamics and physical exam, a non-diagnostic EKG and negative cardiac biomarkers. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for further testing to rule out acute myocardial infarction, as was performed. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. His chest pain was felt to be atypical, and treatment for a non-cardiac etiology was pursued. 

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 inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Auditory hallucinations
Treatment: Continued Inpatient admission 
The insurer denied the Continued Inpatient admission.
The denial is overturned. 

The patient is a male, for whom this was the first psychiatric admission. He was brought to the hospital by EMS and police, who were called by his girlfriend. The patient presented auditory hallucinations and erratic behavior for the previous several weeks. At times, he told his girlfriend that there was a demon inside of him or that someone did voodoo on him. The patient denied substance use other than alcohol and cannabis.

At the time of admission, the patient was described as psychotic, disorganized, and barely able to carry on a conversation due to his psychotic state and internal preoccupation. The patient endorsed some paranoia and a recent increase in praying and possible religious preoccupation. He described feeling "weird and different" recently, and waking up feeling like the day would turn out badly. He appeared to have thought blocking and to be responding to internal stimuli. 

A physician's progress note reports that the patient had refused medication, had periods of irritability, and was less logical in his thoughts and speech than the previous day. He was however able to show kindness to another patient. The following morning the patient's speech was illogical, and he was given Haldol 5 mg.

Yes, the Continued Inpatient admission was medically necessary. 

A severe, acute psychotic episode in this young man with no prior history of psychosis or apparent predisposing factors warranted an additional week of observation and stabilization, after initial improvement, in the interest of safety and preventing regression and re-hospitalization. Discharging or stepping down the patient would not have been consistent with generally accepted practice and guidelines in the Psychiatry community. To do so would have placed his health and safety, as well as the health and safety of his family and community at risk.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Stenosis in the LAD

Treatment: Current Procedural Terminology (CPT) 92978 and 93458-Intravascular Optical Coherence Tomography (OCT)

The insurer denied coverage for Current Procedural Terminology (CPT) 92978 and 93458-Intravascular Optical Coherence Tomography (OCT).

The denial is upheld.

The patient is a male with a past medical history notable for back pain and hypertension. The patient presented to the hospital for chest pain which worsened with minimal ambulation. The patient stated that the pain was in the mid-chest with radiation to the left arm. The patient also reported chest pain several months prior with prior negative stress test results. The patient underwent coronary angiography which revealed 90% stenosis of the left anterior descending coronary artery, for which a coronary stent was deployed with adjunctive assistance of intravascular optical coherence tomography (OCT). This latter procedure was employed to ensure adequate stent apposition. 

There were no procedural complications, and the patient was subsequently discharged home the next day. There is insufficient scientific peer-reviewed literature to support the use and medical necessity of optical coherence tomography (OCT) during percutaneous coronary intervention. This procedure, though approved by the FDA, has not been proven to be more beneficial than angiography-guided percutaneous coronary intervention for treatment of obstructive coronary artery disease. Although there are theoretical benefits to the use of OCT for improved stent apposition to the arterial wall, there is no evidence base that this results in statistically significant improvement in clinical outcomes for patients undergoing coronary stenting. On this basis, the patient is not a good candidate for the use of OCT. Therefore, it is considered that this requested service was not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Current Procedural Terminology (CPT) 92978 and 93458-Intravascular Optical Coherence Tomography (OCT) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Occlusion in the LAD

Treatment: Current procedural terminology (CPT) 92978 and 93458-Intravascular Optical Coherence Tomography (OCT)
The insurer denied coverage for current procedural terminology (CPT) 92978 and 93458-Intravascular Optical Coherence Tomography (OCT).

The denial is upheld.

This is a man with a history of hypertension treated with amlodipine and Diovan-HCT, hyperlipidemia on atorvastatin, obstructive sleep apnea (OSA), kidney stone, and back pain. The patient presented to an outside hospital with a 2 to 3 day history of exertional chest and left arm discomfort with troponin levels 0.02 and 0.05. The patient was transferred with the diagnosis of unstable angina for coronary artery evaluation and possible intervention. The patient's electrocardiogram (EKG) revealed normal sinus rhythm and T wave inversions in the anterolateral leads and subsequent troponin levels were 0.031 and 0.027. The patient underwent coronary angiography which revealed minor luminal irregularities in the left circumflex and right coronary arteries and a 90% LAD lesion, which was treated with a Synergy drug eluting stent. An 80-90% ostial lesion in the tortuous first diagonal artery was not treated with intervention for technical reasons and left ventricular systolic function was normal. The patient was discharged on losartan HCT, carvedilol, aspirin, atorvastatin, amlodipine, omega 3 fatty acids, and ticagrelor.

Although optical coherence tomography (OCT) has FDA approval for use and higher image resolution than intravascular ultrasound, it is primarily used in research trials. There are no current established clinical indications for its use. In addition, the ILUMIEN III: OPTIMIZE PCI trial only demonstrated non-inferiority, not superiority, compared to intravenous ultrasound. Although UpToDate recognizes that OCT may be of use in complex coronary artery interventions such as left main stem, bifurcations, or angiographically ambiguous lesions, this was not the case for this patient. Therefore, this requested service was not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Current Procedural Terminology (CPT) 92978 and 93458-Intravascular Optical Coherence Tomography (OCT) should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased urination and fever; pyelonephritis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female whose inpatient admission is under review. The patient has a history of diabetes mellitus (DM), hypertension (HTN), hearing loss, and breast cancer.  The patient presented with decreased urination and fever (as high as 102 at home). 

Urine analysis (UA) showed six to ten WBC; few squamous epithelial cells, many bacteria, positive nitrite, and trace leukocyte esterase (LE).

Computed tomography (CT) of the abdomen showed abnormal enhancement of the right (R) kidney, stranding, consistent with (c/w) pyelonephritis.

In the ER, the patient was started on intravenous (IV) ceftriaxone for suspected pyelonephritis, and there was thought of discharging on oral (PO) medication. However, the Infectious Diseases (ID) consult doubted this diagnosis (though antibiotics were continued), and other entities were considered. In the meantime, the patient improved and was discharged home.

Yes, the proposed treatment, inpatient admission, was medically necessary.

Outpatient treatment for pyelonephritis in women is given for uncomplicated cases (1). However, in this case the diagnosis was uncertain, and given the high fevers, standard of care would require hospitalization and work-up for fever while receiving antibiotics in such cases. Thus, this admission was warranted, supported by standard of care. Failure to admit such as a patient can lead to loss of function, septic shock, or death.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory system /Other 
Treatment: Surgical services 
The insurer denied vagus nerve neurostimulator  
The denial is upheld

This is a patient, who was diagnosed with obstructive sleep apnea in The apnea hypopnea index was 37.9. It is reported that the patient was continuous positive airway pressure (CPAP) intolerant and that the patient inadvertently removed the mask in sleep. 
No, the proposed health service or treatment Outpatient Services - nerve stimulator - Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
Hypoglossal nerve stimulator devices function by activating the genioglossus muscle, drawing the back of the tongue forward and improving the patency of the airway. The primary study for this device, the Stimulation Therapy for Apnea Reduction (STAR) clinical trial, is a prospective single-group cohort study of the Inspire upper-airway stimulation system developed by Inspire Medical Systems with results published in 2014. Study participants met eligibility criteria with moderate-to-severe OSA if they had difficulty adhering to CPAP treatment. The STAR trial (Strollo 2014) was funded by Inspire Medical Systems, the manufacturer of the technology and is an uncontrolled cohort study. The lack of control group limits the validity of the results of this study, and the cohort of 83% men. It is possible that the funding increased the possibility of bias.
Based on the evidence-based literature, the implantation of a hypoglossal nerve stimulator system for the treatment of obstructive sleep apnea, is not more beneficial than standard treatment as there is insufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea.