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

This is a patient with no significant past medical history who presented with a seizure episode. Her mother states she received a call that the patient was in the laundromat and had a seizure. Emergency Medical Services (EMS) said a witness saw the patient falling, shaking with generalized movements, foaming at the mouth, with eyes rolling, perioral cyanosis and urinary incontinence. The patient did not remember what happened during the episode. She had a headache 5 out of 10 that started when she came to the hospital. She denied vomiting, diarrhea, rashes or any other symptoms. There were no sick contacts or recent travel. There was no family history of seizures or any neurological disease. This is the first time the patient had a seizure and the first hospitalization. In the emergency room (ER), the vital signs were stable. The patient was oriented to person, place and time with normal reflexes and no cranial nerve deficit. She displayed normal reflexes. She was anxious and slightly confused. She was placed on seizure precautions and labs were drawn. An electrocardiogram (EKG) was done which only showed sinus tachycardia. On hospital day one, the patient continued to have short term memory deficits. A head computed tomography (CT) scan was normal. Complete blood count (CBC) and comprehensive metabolic panel (CMP) were normal. The neurologist recommended an electroencephalogram (EEG). The patient was written for lorazepam as needed (PRN). On day 2, the patient had no recurrence of seizure and as per her mother, the patient's memory and activity were at baseline levels. The mother and patient were educated on seizure recurrence. The mother expressed concern for the patient's weight loss over the past few months. An EEG was done and was normal. She was then cleared for discharge home with no medications. Follow up (F/U) with her primary medical doctor (PMD) was recommended in 5 days.
The health plan's determination is upheld.
There are pediatric patients that may require inpatient hospitalization after presenting with seizure but the patient did not meet criteria for inpatient status. At the time she was admitted to the hospital, there was never any mention of altered mental status, she did not have any neurological deficits, she was not toxic appearing, there were no mention of meningeal signs and no intractable vomiting. There was mention in one admission history and physical (H&P) of the patient not being oriented to time but this evaluation was barely 2 hours after her arrival to the ER. Despite this report, the nursing evaluation documents the patient as alert and oriented x 4. The decision was made to admit her less than 2 hours after her arrival. The patient was not allowed a reasonable amount of time of being observed in the ER in order to return to baseline. Her vital signs were stable and her lab results were normal. The patient was admitted with a plan for EEG and Pediatric Neurology consultation. Both could have been done at a lower level of care. For these reasons, an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure 
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.

This is a young female patient with a past medical history of seizure disorder, developmental delay, and congenital heart defect. She presented to the Emergency Department (ED) by Emergency Medical Services (EMS) after having a seizure at school; she had been given Diastat at school. The patient's teacher reported that the patient had started to look lethargic and her pupils were "going in and out".  The patient began to drool and then they sat her down.  It was reported by the teacher's assistant that the patient had another seizure at school the previous day. The patient was noted to be lethargic upon arrival with a baseline function of nonverbal and responsive.  The patient's physical examination revealed that the patient's eyes were open and she was not following commands.  The patient was tested for influenza B and respiratory syncytial virus (RSV) both with positive results.  The patient was admitted to the hospital for the diagnoses of pneumonia, RSV, and seizure disorder. The patient was discharged home after a period of medical stability. 

According to the guidelines provided by the InterQual 2019, the acuity of this case is considered to have required observation as the patient was a known patient with a diagnosis of epilepsy.  The patient required no intervention as it was triggered by a viral infection.  No other interventions were needed.  The patient was described as interactive and was able to be discharged later the same day. The patient did not require an escalated level of care.

The current literature indicates that a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability.  Within the documentation provided for this review, it was noted that the patient presented with a seizure in the setting of an infection that self-resolved.  However, the submitted documentation did not detail that the patient had a trial and failure of care at a lower level, such as observation. The documentation detailed that the patient did continue to slowly improve and was discharged. 

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

Diagnosis: Skin disorder /Acne  
Treatment: pharmacy /prescription drugs  
The insurer denied Tretinoin 0.01% EX GEL. 
The denial is Upheld in  whole .


This is  patient with acne. The patient has been treated with BenzaClin, Bactrim, topical Clindamycin, Adapalene .1% gel, Doxycycline, and Minocycline.
No, medical necessity for Tretinoin .01% gel has not been established. The records submitted include an MD note  where the patient presented for a skin check. At that time the current medications are listed: Bactrim and Clindamycin/Benzyl Peroxide. There is no history with regards to the efficacy of these medications. The records submitted don't chronicle which medications had been tried and failed. The provider indicates that Minocycline and Doxycycline were tried in 2015 but there are no medical records included for review to document this. The medical records actually reflect that the patient had success with Epiduo Forte, but the medication was not continued.  This would not be deemed a failure of treatment. The office note was reviewed and considered. The patient has acne that got worse when the patient  ran out of the requested medication tretinoin .01% gel. Regardless, the patient does not have a documented trial and failure with other options. The Tretinoin .01% gel is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: Hospital admission 
The insurer is denied coverage for hospital admission. 
The denial is upheld. 
This is a female patient who presented to the Emergency Department (ED) with complaints of dizziness. The patient reported that she had an episode of complete visual loss while walking into the bathroom. The patient reported that her vision had remained blurry since the episode. The patient reported occipital pressure which progressed to the rest of her head with photophobia aggravating her symptoms. The patient's physical examination revealed a temperature of 98 degrees with a heart rate of 71 bpm, oxygen saturation was 100% and a blood pressure was 110/58. On exam, the patient was alert and oriented and in no apparent distress. The patient reported that she felt well with the lights off but continued to have blurry vision, head pressure, and heaviness. Neurology was consulted. The patient was given Reglan and intravenous (IV) fluids. Upon recheck, the patient reported mild relief in symptoms. The patient was admitted to the hospital for possible transient ischemic attack (TIA). A magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) was performed that were both unremarkable. The patient had a period of medical stability and was discharged home.

Based on the review of the medical record and the literature, the acute inpatient hospitalization was not medically necessary. The patient initially presented to the Emergency Room (ER) with complaints of blurred vision, dizziness, and headache. The patient's neurologic examination was unremarkable. Notably, the patient had no cranial nerve abnormalities, no weakness, and no sensory loss. The patient was treated for a headache with medications such as intravenous (IV) fluids and Reglan. The patient's magnetic resonance imaging (MRI) of the brain was ordered that was unremarkable. Acute hospitalization for treatment of headache or transient ischemic attack (TIA) was no longer standard of care. The patient had no demonstrated neurologic deficits. The patient's imaging was normal, and the symptoms were more supportive of headache than TIA. The patient did not require complex nursing care or rehabilitation. The patient did not receive tissue plasminogen activator (tPA). Literature support that TIA and headache are routinely treated in observation status and that many patients presenting to the hospital with TIA who are low risk are even discharged home with expedited outpatient follow-up. As such, the acute admission is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient hospital admission 
The insurer is denied coverage for inpatient hospital admission.  
The denial is overturned.
 
This is a female patient with a past medical history of pneumonia, 3hypertension, hyperlipidemia, diverticulitis, gastroesophageal reflux disease (GERD), chronic back pain, status post appendectomy, cholecystectomy, and right hip total arthroplasty, and cigarette smoking.  The patient presented to the hospital with complaints of abdominal; pain rated 4 out of 10, in severity, vomiting and diarrhea for the past for several days. The patient's blood pressure was 184/95, pulse oximetry was 92%, respiratory rate was 16, and her heart rate was 86. The patient reported having had some shortness of breath on ambulation and exertion. The patient's urine was noted to have a smell. The patient's physical examination was normal. The patient's abdomen was soft, tender, and there was no guarding or rebound. Laboratory work up was performed that revealed white blood cell (WBC) count of 23,000, elevated lactic level of 2.4 and hypokalemia of 3.0.  An electrocardiogram (EKG) was done that showed a regular sinus rhythm at 83. A computed tomography (CT) scan of the abdomen and pelvis was performed that revealed thickened distal esophagus, and a mild lymphadenopathy; malignancy could not be entirely excluded. The patient was to receive oral potassium chloride, Pepcid, Zofran, cefepime, and Zosyn. The patient was admitted to the hospitalist service for unspecified abdominal pain. The patient was medically stable and discharged home.

Based on the review of the medical record, the patient presented to the hospital with acute symptoms, as well as abnormal testing including hypokalemia, lactic acidosis, leukocytosis, and CT finding of possible infection or malignancy. The patient had multiple comorbidities that put this patient at higher risk for complication in the setting of possible sepsis. It was imperative that the patient be evaluated adequately and that the patient's treatment plan is provided at an inpatient level of care. Thus, inpatient admission was 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.

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

Diagnosis: Atrial Fibrillation.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man with hypertension, hyperlipidemia, chronic kidney disease (CKD), and atrial fibrillation (AF) on Eliquis, who presented to the emergency room (ER) with a one-week history of dizziness and palpitations. He was in atrial fibrillation with ventricular rates in the 120-130s. Blood pressure (BP) was 145/118 mm Hg and respirations 23. Oxygen saturation was 97%. He was given intravenous (IV) and by mouth (PO) diltiazem.
He was admitted and evaluated in electrophysiology consultation. 

The inpatient hospital admission is not medically necessary. The patient presented with symptomatic rapidly conducted atrial fibrillation and may have tachycardia-induced cardiomyopathy. Urgent treatment is needed. His care, including medication and TEE/cardioversion, was appropriate and within the standard of care per current American College of Cardiology (ACC) / American Heart Association (AHA) guidelines (ref 2 below). However, treatment could have been accomplished at a lower level of care. The patient underwent treatment, including TEE/cardioversion, within the first day of hospitalization and was discharged. Inpatient admission is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Endocrine
Growth Hormone

Diagnosis: idiopathic short stature 
Treatment: Nutropin
The insurer denied Nutropin. The health plan's determination is upheld. 

The patient is a male who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). His mother's height is 61'' and father's height is 68''. His growth chart shows that he was tracking along 3rd %tile for height since the age of 2 years. Apparently, his growth slowed down and his height and weight dropped below 3%tile. By history, his growth velocity was 2 centimeter (cm) per year at that time but a record of that visit is not available. His evaluation at that time showed normal complete blood count (CBC), normal comprehensive metabolic panel (CMP), normal thyroid function test (TFT) , negative celiac screen, low normal IGF-1 (insulin like growth factor 1), low testosterone (12 ng/dl) and a bone age of 11.75 years.

The Nutropin AQ is not medically necessary for this patient
Guidelines for the use of GH in children with ISS recommend against the routine use of GH in every child with height SDS at or below -2.25 and suggest that decision be made on a case-by-case basis.
This patient's growth velocity has already improved since last year with the onset of puberty, and is expected to improve further with the progression of puberty. His most recent bone age was read as 15 months delayed which should give him adult height prediction within 1 SD of his genetics. Clearly, he does not qualify for GH treatment under the indication of ISS. This patient most likely has combination of familial short stature and constitutional delay in growth and pubertal development. He does not qualify for GH treatment under the ISS indication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Maxillary and mandibular crowding.
Treatment:  Dental - braces and monthly orthodontic visits.

The insurer is denied coverage for braces and monthly orthodontic visits.  The denial is overturned. 

The patient was a female with no medical or dental history indicated in the records provided.  As per the treating orthodontist, the patient had crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin were present.  Also, according to the orthodontic treatment program, the patient had skeletal class lll-hypoplastic maxilla, normal vertical growth pattern, late mixed dentition, mild maxillary crowding, mild mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular left canine).  The insurer stated the patient's provider gave her a score of 12 points, and to qualify for braces a score of 26 points was needed. 

The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, Class III malocclusion and anterior crossbite with gingival attachment loss (mandibular left canine).  The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) Index and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  

It is evident that the patient exhibits a significant malocclusion.  However, to assess for the severity of the malocclusion, and therefore medical/dental necessity for orthodontic care, a HLD Index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of
crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This automatically qualifying condition criterion is met and does support comprehensive orthodontic care for this patient.  Thus, braces and monthly visits are considered medically necessary for this patient.

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 braces and monthly visits should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left-sided chest pain, headache, and blurred vision.
Treatment:  Inpatient admission.

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

The patient is a female with diabetes and hypertension, who presented to the emergency department with left-sided chest pain, headache, and blurred vision.  The blood pressure on presentation was 197/126 with a pulse of 91 and oxygen saturation 100%.  Labs were notable for a creatinine 0.7, bicarbonate 28, hemoglobin 10.5, brain natriuretic peptide 102, and glucose 236.  Computed tomography of the brain and the chest x-ray showed no acute process.  The electrocardiogram showed sinus rhythm without acute ischemic changes, and cardiac enzymes were negative.  The patient was monitored on telemetry.  Hydralazine was initiated, and the amlodipine dose was increased.  Blood pressure control progressively improved.  Diabetic education was provided for a hemoglobin A1C of 11.1.

No, the proposed treatment is not medically necessary. 

The patient's chest pain was not accompanied by evidence of acute coronary syndrome, pulmonary embolism, or aortic dissection.  The electrocardiogram showed no acute ischemic changes, and cardiac enzymes were negative.  There was no acute intracranial process or focal neurologic episode.  Computed tomography of the brain demonstrated no acute process.  The elevated blood pressures were not accompanied by evidence of hypertensive emergency, as there was no end organ damage (hypertensive encephalopathy, acute cerebrovascular accident, intracranial hemorrhage, acute heart failure, papilledema, microscopic angiopathic hemolytic anemia, acute kidney injury, or seizure disorder).  The blood pressure improved with oral antihypertensive agents; intravenous antihypertensive agents were not required.  There was no evidence of diabetic ketoacidosis or nonketotic hyperosmolar state.  In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Open wounds of calf and foot
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient was admitted for six days after skin grafting for open wounds of the calf and foot. The medical necessity of this stay is under review.

Yes, the proposed inpatient admission was medically necessary.

This patient presented for scheduled split-thickness skin grafting of open wounds of the right calf and foot. The procedure was performed and was uneventful. The patient was admitted to the hospital and remained for six days.  

During the patient's hospital stay, he was non-weight-bearing (NWB) on the right leg, the side of the skin grafts. He was evaluated and treated by physical therapy (PT) and occupational therapy (OT). The patient was also seen by an Endocrinology consultant for management of his glucose.

The postoperative care consisted primarily of gradual increase in the patient's ambulation. He was ordered to be at bedrest on the day of surgery, but he was allowed out of bed and NWB on postoperative day #1. He was able to get around only with the help of OT and PT providers. Over the ensuing five days, he gradually increased his ambulation. He required significant assistance on day #1, but his need for help gradually declined over the course of his hospital stay. Despite this improvement, he was not functional enough to be independent until the date of his discharge.

The patient needed virtually no intervention from the Endocrinology consultant because his glucose was well controlled throughout his hospital stay on his home regimen. The patient did not exhibit any instability. His surgical site was intact, and he had no cardiovascular problems.

Although the patient did not have acute medical problems, the care given to him could not have been provided in an outpatient ambulatory setting. The reason is that he was not able to get around independently.