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

Diagnosis: Shortness of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female with no significant past medical history. She presented to the ER for further evaluation/management of dyspnea. 

The patient's intake vitals were noted to be afebrile, hemodynamically stable and non-hypoxemic on room air. Physical examination was non focal with no significant abnormalities noted, with the exception of initial mild tachycardia and diminished breath sounds in the bases. Laboratory testing was notable for elevated HCG (Human Chorionic Gonadotropin) values of 18,817 and mild leukocytosis. Imaging studies including a chest CT were negative for pulmonary embolus or other abnormality. Blood cultures were no growth to date. 

The patient was admitted to the inpatient medical service in stable condition, where she received treatment with IV fluids, broad spectrum IV antibiotics, steroids and bronchodilators. She improved with the prescribed therapies and was subsequently discharged in stable condition. 

The patient is a female with no significant past medical history who presented to the ER for further evaluation/management of dyspnea. Intake vitals were noted to be afebrile, hemodynamically stable with no evidence of severely elevated temperature, severe tachycardia, profound hypotension or significant hypoxemia on room air. Physical examination was non focal with no significant abnormalities noted with the exception of initial mild tachycardia and diminished breath sounds in the bases. There was otherwise no evidence of accessory muscle use, respiratory distress, tachypnea or end expiratory wheezing. Laboratory testing was notable for elevated HCG values of 18,817 and mild leukocytosis but no findings consistent with end organ damage. Imaging studies including a chest CT were negative for pulmonary embolus or other abnormality. Blood cultures were no growth to date. 

The patient was admitted to the inpatient medical service in stable condition where she received treatment with IV fluids, broad spectrum IV antibiotics, steroids and bronchodilators. She improved with the prescribed therapies and 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 Inpatient Admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria

Treatment: Breast surgery (augmentation mammoplasty)

The insurer denied coverage for breast surgery (augmentation mammoplasty). The denial is reversed.

This patient is a transgender female with a history of asthma. Based on the review of the World Professional Association for Transgender Health (WPATH), this patient with gender dysphoria associated with body image met the clinical criteria for breast augmentation procedure. Although not an explicit criterion, WPATH recommends male-to-female patients undergo feminizing therapy (minimum of 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results. In this case, the patient has been on hormone therapy for a couple of years. Breast growth with hormone therapy has been maximized. Yet, this patient's breast size was noted to have plateaued at size A-cup, and was causing persistent symptoms of gender dysphoria. The patient was capable of making a fully informed decision and had consented for the treatment. Though significant mental health concerned were not documented, this patient's mental health professionals and endocrinologist supported this patient's plan for breast augmentation and indicated that this procedure was an essential component of this patient's overall treatment for gender dysphoria. The requested breast augmentation is consistent with the WPATH criteria for gender dysphoria, and is thus, considered medically necessary to treat this patient's medical condition.  

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

The carrier's denial of coverage for breast surgery (augmentation mammoplasty) should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroparesis
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient hospital stay. 
The denial is upheld.

This patient is a female with a past medical history of hyperlipidemia, hypertension, hypothyroidism, asthma, chronic obstructive pulmonary disease (COPD) Graves' disease, depression, anxiety, gastroparesis (status post gastric pacemaker placement), status post appendectomy, cholecystectomy, and thyroidectomy. The patient presented to the emergency department with nausea, vomiting, abdominal pain, and diarrhea.  The patient's blood pressure was 155/118 and her saturations were 99% on room air.  The temperature was 97.3F.  The abdomen was soft and non-distended.  There was no rebound and no guarding.  There was generalized pain on palpation.  There were no bowel sounds in all 4 quadrants.  The patient's white blood cell count was 13.53 and her lactate was 1.3.  Her lipase was 33.

The patient was treated with intravenous fluids, morphine, and Zofran.  The patient was given Dilaudid for pain without improvement.  The patient refused to drink contrast for a CT scan.  The provider indicated that the patient had a medical necessity beyond the capabilities of an emergency department and there was a concern for intractable vomiting.  The patient was admitted with a diagnosis of intractable vomiting.  The patient was initially treated with nothing by mouth and was seen by Gastroenterology.  The patient was treated with intravenous pain medications and multiple doses of Zofran.  The patient's diet was advanced on and she was discharged.

This patient was admitted with a diagnosis of probable gastroparesis.  She showed no signs, symptoms, or laboratory data to suggest toxicity or criteria to warrant hospital admission as inpatient rather than observation.  Patients that need hospitalization are those with the following signs and symptoms:  Volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as HIV and diabetes (immunocompromised status), age >=65 years, recent hospitalization or antibiotics, pregnancy, or weight loss.  

The inpatient hospital stay was not medically necessary. 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 stay from is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation

Treatment: Inpatient admission

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

The patient was a male who presented to the Emergency Department (ED) at a hospital due to an in-office electrocardiogram (EKG) that showed atrial fibrillation. The patient reported a history of palpitations for one week. The patient took 1 dose of Xarelto at his primary care physician's office prior to arriving to the ED. The patient's EKG at the ED indicated atrial fibrillation with a heart rate of 114. The patient's initial lab work in the ED showed an international normalized ratio (INR) of 2.4 with serial negative troponin levels. Cardiology was consulted. The patient was admitted to the Telemetry unit with a diagnosis of atrial fibrillation.  The treatment plan included switching from Xarelto to Lovenox because the patient was suspected of having rheumatic heart disease. The patient was also on Metropolol.  The patient was on continuous heart monitoring. However, the patient continued to show atrial fibrillation on his EKGs with a heart rate in the 90s. The patient was transferred to another hospital for rheumatic mitral valve surgery.  

Based on the review of the medical record, the patient presented with atrial fibrillation. The remainder of the patient's cardiac workup was unremarkable, including unremarkable cardiac troponin. The patient remained clinically and hemodynamically stable throughout the hospitalization. Inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, this patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Inpatient admission criteria were not met for this patient.  Although the patient had new onset symptoms, the patient did not have extenuating circumstances that required inpatient monitoring and care. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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: Overturned

Diagnosis: Coronary artery disease
Treatment: Inpatient Admission
Decision: Approved. 
The inpatient admission denial is overturned.

Summary:
The patient is a male with a past medical history significant for HTN (hypertension), diabetes mellitus type 2, CAD (coronary artery disease), who presented for complaints of syncope, which occurred twice, associated with diaphoresis. The patient was evaluated in outpatient setting in his doctor's office and was found to have new abnormalities on ECG, including a new Q-wave and ST changes. Prior stress test revealed ST depressions in inferior-lateral leads, which was treated medically. The patient was referred to the ER. He was hemodynamically stable. His cardiac troponin was negative. 

The patient presented with new onset syncope in the setting of diaphoresis, acute symptoms concerning for ventricular arrhythmia in the setting of ischemia, unstable angina. The patient had multiple risk factors for CAD, including diabetes, as well as a known history of coronary artery disease, requiring percutaneous revascularization. The ECG was unrevealing for ACS (acute coronary syndrome), but was abnormal, with findings suggestive of prior myocardial infarction and ischemic changes. Prior stress test ECG was abnormal as well. There was a high index of suspicion for an ACS, and a cardiac catheterization was performed, which in fact revealed severe lesion of the proximal LAD, and a stent was implanted. Given the presentation, unexplained syncope, as well as clinical suspicion for an acute coronary syndrome/VT/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit or outpatient follow-up, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Depression, anxiety, and symptoms consistent with Attention Deficit Disorder.
Treatment:  Continued inpatient residential treatment.

The insurer denied the residential treatment.  The denial is upheld. 

The patient is a female who was admitted to a residential treatment center. 

The patient did not demonstrate behavior or symptoms requiring the intensity and restriction of residential level of care.  She did not engage in unsafe or significantly inappropriate behavior toward herself or others.  Reported inappropriate sexualized behavior was described as being that which she engaged in prior to attending this program.  She did not require intensive staff intervention to keep her or others safe.  She did not report or exhibit significant anxiety or depressive symptoms; for the most part she was described as happy and in a good mood.  She successfully engaged in school, all treatments, on and off grounds activities including volunteer job positions, and off grounds passes.  She did not require complex medication monitoring or changes; she saw a psychiatrist twice during the time in question, and was only taken off of her medication.  She had no significant medical complications.  She did not report a significant history of substance use and indicated that she is not interested in engaging in substance use in the future.  She did not report cravings and did not idealize past use.  While she continued to demonstrate difficulty with social cues, social skills, interactions, impulse control, judgment and emotional expression, these are related directly to a neurocognitive disorder, for which she will require lifelong targeting with treatment and/or monitoring.  Her neurocognitive issues, while significant, could be addressed in a less intensive setting than a residential treatment center.  The patient demonstrated the ability to make progress in all areas targeted, suggesting that she could make gains as well in a less intensive setting.  Her parents were active and supportive and demonstrated the ability to understand her neurocognitive issues and the need for a developmental perspective and increased structure and supervision.  The patient had demonstrated the ability to make gains in her prior residential treatment program.  After an unsuccessful and unsafe pass home, just prior to her graduating from this program, she was readmitted to a wilderness program and then this current residential program.  During both she demonstrated the ability to be reengaged successfully in treatment and to demonstrate overall stable and safe behavior.  She was ready to be stepped down to a lower level of care where she could continue the lifelong work she will require.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was reversed.

This is a male patient with a history of hypertension, non-compliance with medications, hepatitis C, tobacco, alcohol and cocaine abuse.  He presented to the Emergency department with complaints of sharp substernal chest pain. He reported that his wife had died and his son left; as a result he used cocaine. His initial vital signs included BP 204/129, temperature 99.0 F, heart rate 105, respiratory rate 21, and oxygen saturation on room air 100%.  An electrocardiogram (EKG) was performed that revealed sinus tachycardia with only non-specific ST-T abnormalities.  A chest x- ray was done that revealed only peribronchial cuffing.  Laboratory test were performed that included WBC 5.3, hemoglobin 11.9, creatinine 1.7, troponin 0.05, with subsequent troponin levels 0.04 and 0.03.  CPK was 994.  He was treated with intravenous (IV) saline with decrease in CPK to 460 and then to 216; Creatinine also decreased. Urine screen was positive for cocaine.  He was treated with IV Ativan, hydralazine, and aspirin.  A computed imaging (CT) scan of the chest done that revealed patchy airspace disease at the left lung base, with emphysematous changes, and the pulmonary consultant recommended treatment with intravenous ceftriaxone and azithromycin.  An echocardiography was done that revealed left ventricular hypertrophy with grade I diastolic dysfunction and left ventricular systolic function 60-65%. Psychiatry was consulted. It was suggested that the patient had a mood disorder, with recommendations for and hepatitis panels. The patient was discharged on antibiotics, Procardia and HCTZ with outpatient follow-up.

This patient presented after use of cocaine with chest pain along with multiple other issues including elevated creatinine, CK that was borderline for rhabdomyolysis and Tn at upper levels of normal with ECG changes that while not diagnostic, did include STT changes.  Also, there was evidence suggestive of pneumonia along with neutropenia. He was treated for pneumonia. 
Given the multiplicity of these findings it was reasonable to admit for acute inpatient management. 

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

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

Diagnosis: Asthma.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient who has a history of asthma and smoking. She presented to the Emergency Department (ED) with complaints of shortness of breath and chest tightness. The patient had been on oral steroids for a few days as an outpatient. Vital signs at presentation included a temperature of 98.1F, a heart rate of 125, a respiratory rate of 19, a blood pressure of 154/97 mm Hg and an oxygen saturation of 98% on room air. The patient was awake and alert. There was non-labored respiration. Lung examination noted bilateral wheezing. A cardiac exam was within normal limits.
The patient was treated with steroids and bronchodilators with some improvement.  Her peak expiratory flow (PEF) rate was about 100. Laboratory work up was performed that revealed a white blood cell (WBC) count of 9.1K, a hemoglobin of 13 and electrolytes were within normal limits. A venous blood gas (VBG) revealed a pH of 7.38, a partial pressure of carbon dioxide (pCO2) level of 45 and a partial pressure of oxygen (pO2) level of 63. A chest x-ray showed no acute infiltrates. An electrocardiogram (EKG) was performed that showed no acute ischemic changes. The patient was continued on intravenous (IV) steroids, bronchodilators and Doxycycline. The patient showed some relief after treatment in the ED but was admitted to the hospital with continued wheezing with a low PEF.

The patient remained afebrile and hemodynamically stable. Vital signs revealed a temperature of 98.4F, a blood pressure of 140/89 mm Hg, a heart rate of 97, a respiratory rate of 18 and an oxygen saturation of 95%. The patient was in no acute distress. She was symptomatically better. There was no accessory muscle use. Lungs still had mild wheeze and the PEF was 180. The WBC count was 8.1, the hemoglobin was 13 and electrolytes were within normal limits. The plan was to taper steroids.

This patient did not need acute hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was afebrile and hemodynamically stable. There was no pneumonia. She was not hypoxic and the WBC count was normal. The patient's PEF was low, but her baseline was not known. The patient started responding after initiation of treatment. The patient could have been switched to oral medications and then discharged home on steroids, bronchodilators and oral antibiotics as clinically indicated. By the next day the patient remained stable and was tolerating oral intake. Her PEF had improved to 180 and the patient was stable for discharge with close follow-up in an outpatient setting. The patient's PEF was 200 when she was discharged.  
The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

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

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient who presented to the Emergency Room (ER) with complaints of a right leg lesion, fever, and walking with a limp. The patient reported that he had traveled to Dominican Republic where he sustained several insect bites. The patient's lesion began as a blister and was noted to rupture the day prior to admission, with a pussy discharge. His presenting vital signs were: heart rate was 80, respiratory rate 20, blood pressure 113/63, and oxygen saturation was 99%. A physical examination was performed that revealed lower leg cellulitis approximately 9x9 cm with a 2x2 cm central ulcer. The patient had no rash, neurological impairment, or vascular compromise. Laboratory work up was performed that revealed white blood cell (WBC) count of 13,000 (i.e. pediatric normal range 5-15000/mm3). The patient's medical treatment included intravenous (IV) antibiotics, Tylenol and wound care. The patient was medically stable and discharged home. 

Based on the review of the medical record and the literature, there is no justification for continued treatment at an inpatient level of care. The patient had no sign of hemodynamic instability, progression of disease, or any abnormal local signs to suggest a deep tissue infection; there was no evidence of sepsis and the patient's cellulitis was not extensive.  There was no clinical evidence of septic arthritis, myositis, or fasciitis.  This was most likely an insect bite allergic reaction with mild superimposed staphylococcal bacterial infection.  Both the antibiotic (clindamycin) and pain medications could have been administered orally, with follow-up as an outpatient.  This is consistent with standard practice for an adolescent patient with mild to moderate cellulitis. Thus, inpatient admission was not medically necessary. 
 
The health care 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.