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

Diagnosis: Diabetic Ketoacidosis without coma and dysfunction, Metabolic Acidosis, and Hyperkalemia.

Treatment: Inpatient Hospital

The insurer denied the Inpatient Hospital.  The denial was reversed.

This is a female patient with a past medical history significant for diabetes mellitus who presented to the emergency room in late 2019 with a chief complaint of decreased appetite for 2 days, nausea and vomiting for 1 day.  In addition, the patient reported lung and back pain.  The patient stated she remembered feeling similar symptoms with a prior incidence of diabetic ketoacidosis (DKA).  The patient reported her pain was severe and vital signs were 129/58, heart rate of 123, temperature of 97.3, respiratory rate of 20 and oxygen saturation of 95% on room air.  The lab values were: blood glucose of 678, BUN of 25, white blood cell count of 2.9, potassium of 7.1, urinalysis revealed glucose of 500, and ketones of 80.  An EKG performed also revealed sinus tachycardia.  The patient was admitted to ICU on an insulin drip with a diagnosis of diabetic ketoacidosis without coma and dysfunction, metabolic acidosis, and hyperkalemia.

The MCG list specific indications for admission as an inpatient including severe electrolyte abnormalities that is not as expected for patient baseline or acceptable treatment effects such as Potassium greater than 6.5mEq/L and a severe medical etiology.  
The MCG list specific indications for admission as an inpatient for management of diabetes including etiology of diabetic ketoacidosis unclear, i.e., not thought to be secondary to missed insulin doses, hyperglycemia requiring inpatient care as indicated by one or more of altered mental status, dehydration, vomiting or significant electrolyte abnormality.  

Based on the above, the medical necessity for the inpatient hospital services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polyuria and nocturnal enuresis
 
Treatment: Inpatient admission; Initiation of insulin treatment 


The insurer denied the coverage for Inpatient admission. The denial was reversed.

This patient is a male child who presented with polyuria and nocturnal enuresis. The patient started noticing increased thirst one week prior to admission.  He went to the primary care physician (PCP) where his hemoglobin A1C was elevated to 8.6% and the blood glucose was 612. PH was normal and bicarbonate was normal.  The patient was found to have glucose and ketones in the urine.  He was started on intravenous fluids to clear the ketones.

In this case, the patient was a child who presented with new onset type I diabetes requiring insulin initiation and adjustment of insulin doses and diabetes education for the family.  The request is consistent with generally accepted standards of medical practice and is therefore medically necessary. The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admissionis reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
 
Treatment: Inpatient admission, monitoring

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

This case involves a female who was transported to the hospital due to feeling weak.  The impression was syncope/fainting.  The physical examination was normal; she had no facial droop and the home aide stated that the patient's face looked normal.  The patient had mild weakness to the left arm with arm drift. The patient had a past medical history of subarachnoid hemorrhage status post coiling aneurysm, refractory hydrocephalus, VP shunt, chronic stroke, depression, anxiety and hypothyroidism.  She underwent a CT scan of the head which revealed no changes, and a CT of the chest that revealed no pulmonary embolism or acute finding. A Troponin level was negative and a lactate level was elevated at 1.50.  The patient underwent a shunt-o-gram, which revealed the VP shunt was working appropriately.  Laboratory studies and examination ruled out an acute infarction.  A stroke code was activated.  The patient was alert and oriented x3, and she had a National Institutes of Health stroke scale score (NIHSS) of 0. The chief complaint on admission was syncope. The patient was subsequently stabilized and discharged.

The MCG indicate that observation would be appropriate for patients at risk for cardiogenic etiology of syncope warranting further testing or observation as indicated by an age of 50 years or older or a family history of sudden cardiac death.  It would also be appropriate for patients with syncope features not consistent with neurally mediated syncope as indicated by a sudden loss of consciousness. Inpatient admission would be appropriate for a patient who has hemodynamic instability, or an altered mental status that is severe or persistent, or who has a cardiac disease or finding that necessitates immediate intervention.  It would also be appropriate for other conditions, treatment, or monitoring requiring inpatient admission. The patient had a sudden loss of consciousness. A NIHSS stroke score was 0 and the patient was alert and oriented x 3.  The records failed to support the patient could not have been cared for at a lower level of care, such as observation.  

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

Diagnosis: Malignancy - Leukocytosis and Failure to Thrive

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was upheld.

The patient is a female baby who was referred by her pediatrician for evaluation of high WBC.  The record indicates that the child was seen for well child care and had an elevated WBC; on repeat CBC was noted to have WBC 28.4.  Hospital note details "Per mom, the patient is acting at baseline, although gaining weight slowly. No easy bruising, rashes, fevers, night-sweats." On physical examination at presentation the patient is described as "Well-appearing child, active, alert" and no lymphadenopathy or hepatosplenomegaly is demonstrated. 

Leukocytosis in a well appearing and afebrile child does not require hospitalization unless there are other concerning signs and symptoms that require immediate evaluation or monitoring (1).  The review of symptoms was reassuring as was the physical exam making malignancy or severe infection highly unlikely.  In an otherwise well-appearing child for whom the plan is simply repeating blood tests, hospitalization is not required.  In fact, the consulting expert made the suggestion that hospitalization was "not indicated."  Serial exams and blood tests as an outpatient would have been appropriate until there was a determination to perform more invasive testing.

Failure to thrive is a concern that rarely requires hospitalization as well, and there were no clear features in this patient's presentation that required hospitalization for failure to thrive.(Ref 2, 3) "Hospitalization is rarely required, and most children with FTT are managed as outpatients. The lack of benefit to hospitalization in most cases has been apparent for decades.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD) exacerbation

Treatment: Inpatient admission, intravenous medications, bi-level positive airway pressure, nebulizers, diagnostics

The insurer denied inpatient hospital services. The denial was upheld.

This patient was brought via ambulance to the Emergency Room (ER) due to shortness of breath. Chest x-ray showed exacerbation of chronic obstructive pulmonary disease (COPD).  The patient was started on Solu-Medrol, Zithromax and DuoNeb.  Flu and respiratory syncytial virus (RSV) tests were negative.  The patient has a history of hypertension and chronic obstructive pulmonary disease (COPD) and complained of some productive cough with yellow sputum.  The patient was placed on bi-level positive airway pressure (BiPap).  Lung exam revealed bilateral expiratory wheezes.  Treatment included nebulizers, intravenous (IV) steroids, magnesium and Azithromycin. Cardiac enzymes were negative.  Brain natriuretic peptide was normal.  EKG showed normal sinus rhythm.  There were no acute changes.  Influenza screen was negative. Chest x-ray showed no acute infiltrates.  The patient reported symptom improvement after treatment in the ER.  

This patient did not need acute hospitalization. The patient responded to treatment in the ER and remained stable after admission.  The patient was in no acute distress.  The patient was tolerating oral intake. The patient's exacerbation had been due to his inability to obtain prescribed inhalers. The patient was stable for discharge after a period in observation, with follow-up care as outpatient and procurement of needed inhalers.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency room (ER) with 10/10 right upper quadrant (RUQ) pain.  Past medical history was notable for varicose veins.  The white blood cell (WBC) was 9.4k.  An ultrasound showed a stone in the neck with gallbladder wall thickening.  General surgery was consulted for a diagnosis of acute cholecystitis.  Antibiotics, fluids and antiemetics were ordered.  Lap cholecystectomy was performed on 1/16/19 with evidence of acute cholecystitis. 

The health plan's determination is overturned.  The inpatient stay was medically necessary for this patient.  This patient does meet criteria for an inpatient admission based on the provided medical records.  This patient had evidence of acute cholecystitis on ultrasound with a left shift and a positive Murphy's sign with and guarding on physical exam.  She required IVF for resuscitation, anti-emetics and IV antibiotics for source control prior to definitive surgical intervention.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  who presented to the emergency room with right vulvar pain and drainage. Her exam showed vulvar erythema and a fluctuate mass consistent with an abscess. It was tender to palpation. Vital signs showed a temperature of 100.7 degrees Fahrenheit (F) otherwise, they were normal. Her white blood cell count was 18.5. A pelvic ultrasound was normal. She was admitted as an inpatient and was given intravenous antibiotics and oral antibiotics with pain management. The abscess was aspirated with a needle by midwife with 3 cubic centimeters (cc) of fluid.  The health plan's determination is upheld
The patient presented and was diagnosed with a vulvar abscess in the emergency department. Fluid was aspirated by the nurse midwife, however, no incision and drainage was attempted. In addition, no oral antibiotics were attempted nor was any other outpatient management attempted prior to admission. She was febrile, however, she was not hemodynamically unstable as all of her vital signs were normal. She had no other medical morbidity to support the need for inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

The patient underwent a three level anterior cervical discectomy and fusion (ACDF) C4 to C7 for severe cervical degenerative disc disease with kyphotic deformity, radiculopathy and myelopathy. The operative note documents that the procedure was made more difficult by the patient's large body habitus. According to the operative note, after each discectomy and decompression of the neural elements was completed a polyetheretherketone (PEEK) implant was packed autograft augmented by allograft then implanted into the interbody spaces. In the section of the operative note titled "Implants" it is documented that Amendia Orios Bone matrix 2.5 cubic centimeter (cc) was utilized, although the provider dictated that the PEEK implants were filled with Viagraft, allograft and autograft.
The question revolve around the denial by the health plan of the utilization of the "Tissue Matrix & SP Cell BN MTRX" (which was confirmed to be the same as "Amendia Orios Bone matrix" as detailed in the operative report) in this procedure.
The health plan's determination is upheld.

It is necessary for many spinal fusion procedures to routinely utilize bone graft extenders to enhance and promote boney fusion and achieve success for the patient. While autograft is the gold standard, there is a limited supply and particularly in fusion cases where interbody cages are utilized, with the need to fully pack in and around the cages, there is the need for bone extenders. There are numerous categories of bone extenders available, including demineralized bone matrix (DBM), cellular-based matrix (CBM) (of which the Amendia Bone matrix is one), synthetic bone grafts, autologous cellular grafts and Class III Drug-device combination products such as bone morphogenetic protein (BMP). There is a theoretical benefit to CBMs as they add osteoinductive potential to the osteoconductive scaffolding of DBMs, and therefore should increase fusion rates and surgical success for patients.

However, there have been no precision randomized controlled trials (PRCTs) evaluating this theoretical benefit. In addition, because these products fall under the human cell tissue/products (HCT/P)-regulated products clinical data are not required for CBMs prior to commercialization. (See below). Therefore, these products can be introduced without FDA review of clinical data for safety and efficacy. While CBMs represent a promising grafting technology, the current literature does not support its routine utilization until more robust investigations are carried out.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chills, diarrhea, vomiting
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 

This patient with history of polysubstance abuse with illicit substances and EtOH presented to the ER for further evaluation/management of chills, diarrhea, nausea and vomiting. The patient's intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. The patient's examination was non focal, with no significant abnormalities noted, including no evidence of acute cardiopulmonary abnormalities, significant neurologic deficits or findings consistent with acute/surgical abdomen. The patient's laboratory and ECG testing was without critical abnormalities, including no evidence of acute end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received supportive care with IV fluids, IV electrolytes, PRN benzodiazepines and anti-emetics. The patient responded well to the prescribed therapies, and the patient was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episode

Treatment: Inpatient Admission to Telemetry

The insurer denied the coverage. The denial was upheld.

This female patient was brought in by EMS for evaluation of probable syncopal episode that occurred at home. The patient's significant other stated that he was in another room and heard a crash in the kitchen where the patient had been cooking.  When he came out she was lying on a garbage can and her arms and head was twitching slightly.  He noted that the patient's eyelids were fluttering.  This went on for a few seconds and the patient became awake and responsive. Blood pressure was 123/58 with a pulse of 104, temperature 99.2, and oxygen saturation 95% on room air.  The patient had a pain score of 5.  On examination, there was slightly decreased breath sounds and faint crackles at the bases bilaterally.  There was mild mid thoracic spinous process tenderness to palpation.  There was an approximate 3 cm length laceration to the left side occipital scalp.  The patient was alert and oriented with appropriate responses. A CT of the head revealed no acute changes.  X-rays of the thoracic spine revealed no acute fractures.  The patient was diagnosed with syncope and collapse. 
  
The patient tolerated the sutures well with no complications.  There was no indication that the patient had findings of hemodynamic instability, altered mental status that was severe persistent, diagnosis requiring inpatient admission, cardiac disease or findings that necessitated immediate intervention, cardiac ischemia, sustained or symptomatic ventricular tachycardia, bradycardia or sinus pauses, supraventricular tachycardia, atrial fibrillation with rapid ventricular response, pacemaker malfunction, dehydration that is severe persistent or syncope causing injury requiring hospitalization.  The patient's condition was appropriate for level of observational care rather than inpatient level care
Appeal type: Medical necessity
Decision: Overturned

The patient is a married and unemployed male who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol and stimulant (crack cocaine) use disorders. The health plan's determination is overturned. 

The patient in this case presented with a diagnosis of severe alcohol and stimulant use disorder. The patient also had severe psychosocial stress involving spouse's terminal illness and legal issues with risk for re-incarceration. The presenting clinical features and history and risk for withdrawal seizures and other psychosocial complications of alcohol and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively provided at a lower level of care in this case scenario. Withdraw symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care. And, the additional days of treatment were necessary in order to bridge the patient to rehabilitation treatment, as noted in the clinical summary.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with no chronic medical problems other than seasonal and food allergies, who is receiving growth hormone (GH) therapy for idiopathic short stature and poor growth velocity. Pre-treatment height in 2017 was 126 centimeter (cm) (height standard deviation score [SDS] -2.13) and weight was 26.5 kilogram (kg) (weight SDS -1.36) at which time he was pre-pubertal. Mid-parental target height was 65.5 inches. Bone age was 8 years at a chronological age of 10 3/12 years. Insulin-like growth factor-1 (IGF-1) level in 2016 was 97 nanograms per liter (ng/L), and insulin-like growth factor binding protein-3 (IGFBP-3) 2558 nanograms per milliliter (ng/mL). Screening lab tests, including chemistry profile, complete blood count (CBC) thyroid function tests, and celiac screening were normal. Provocative GH testing with clonidine and Levo (L)-Dopa in 11/17 revealed a peak GH response of 19.1 ng/mL. The patient initiated GH therapy in 2018 for idiopathic short stature and has growth velocity increased to 8.5 cm/year. The health plan's determination is overturned.

Yes, GH therapy is medically necessary for this patient. His pre-treatment height was more than 2 standard deviations (SDs) below the mean for age and gender and below his genetic target height, growth velocity was poor, and bone age was delayed. Pre-treatment adult height prediction based on his bone age and height measurement was less than (<) 63 inches. He had an improvement in growth velocity on GH therapy without adverse effects. Continuation of therapy is medically necessary in order for him to achieve his height potential.

According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of the above criteria.

The Food and Drug Administration (FDA) has approved GH therapy for children with short stature and adult predicted height in males of < 63 inches.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant (RUQ) abdominal pain
 
Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission. The denial was upheld.

The female patient had a history of a common bile duct (CBD) stone requiring an endoscopic retrograde cholangiopancreatography (ERCP) and stent replacement previously. She now presented with right upper quadrant (RUQ) abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A CAT scan did not show bile duct dilatation. She underwent an ERCP with removal of the stent. A small retained CBD stone was also removed. Subsequently, she felt better.

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) include the presence of cholangitis that is manifested by evidence of common bile duct disease and systemic signs of inflammation. In this case, there were no systemic signs of inflammation. There was no fever or leukocytosis. The patient also did not have hemodynamic instability, severe pain, severe dehydration or bacteremia.

This patient required removal of a CBD stent and small stone. There was no evidence of cholangitis or sepsis. The procedure could have been performed on an outpatient basis. She did not meet MCG criteria for admission for gallbladder or bile duct stone or inflammation. The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient presented for evaluation of a new onset chest pain, suspicious for unstable angina. The patient had multiple risk factors for CAD, including diabetes, as well as a known history of coronary artery disease, requiring prior surgical and percutaneous revascularizations. The ECG was abnormal, suspicious for an acute MI (myocardial infarction). The cardiac troponin was abnormal with mild elevation. The management of this patient's case was complicated by the presence of significant co-morbid conditions, including renal insufficiency, heart failure, etc. Given the presentation, multiple risk factors, abnormal ECG and troponin, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she was not an appropriate candidate for an ED chest pain observation unit. It was be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.