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

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a woman with history of prior stroke and recurrent TIAs (transient ischemic attacks). She presented with recurrent episodes of altered mental status involving eyes rolling back, inability to speak, tongue sticking out and thrashing followed by lethargy. She had two episodes in the 48 hours prior to admission.

There was concern that the patient was having seizures. She was admitted for IV (intravenous) anti-epileptics, EEG (electroencephalogram) monitoring, continuous cardiac monitoring. EEG (electroencephalogram) showed diffuse slowing, and the patient was eventually discharged on Vimpat.

The health plan denied coverage of the inpatient admission, as it was felt that the admission was not medically necessary. This denial is being appealed.

Yes, the Inpatient admission was medically necessary.
There was concern for seizures and multiple seizure-like activity in 24 hours. This raised the possibility of non-convulsive status epilepticus. Therefore, the patient required admission for EEG (electroencephalogram) to rule out continuous seizures. Furthermore, she required continuous telemetry monitoring, which is a requirement for inpatient hospitalization per MCG (Milliman Care Guidelines) guidelines. For these reasons, the inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient required EEG (electroencephalogram) monitoring and continuous telemetry monitoring to rule out seizure activity and ensure that her vitals were stable. Not admitting patient for EEG (electroencephalogram) and continuous telemetry would deviate from standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute encephalopathy

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient presented to the emergency room (ER) with altered mental status and also found to have glucose of 470. Upon examination, slurred speech was noted. The patient received intravenous (IV) fluids. The patient was admitted for acute encephalopathy secondary to new onset of diabetes. The patient received subcutaneous insulin and also endocrinology consultation, nutrition consultation. The patient's glucose improved, and he was discharged.

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

Inpatient hospital admission is considered medically necessary for this patient. This patient presented with altered mentation and severe hyperglycemia without known diabetes regimen. The severity of symptoms qualifies for diagnosis of hyperosmolar hyperglycemic state. He required frequent exams, glucose monitoring, IV fluids, insulin, and diabetic teaching that could not be accomplished at an observational level. Therefore, the hospital stay at an inpatient level is medically necessary.

Gosmanov AR et al. (2021), "Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises' management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential special situations such as DKA or HHS presentation in the comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis"

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic Lung Cancer.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient has the medical diagnosis of cancer. The patient has been seen and treated for cancer. The patient has undergone biopsy (bx). The patient has biopsy proven metastatic cancer. The patient has an unknown primary cancer site. with metastatic breast cancer. The patient was non oral chemotherapy (chemo). The patient presented to the emergency room (ER) with chest pain. The patient's radiographic imagining showed metastatic lesions. The patient was in sinus tachycardia. Cardiac enzymes were negative. The electrocardiogram (EKG) showed non-specific T waves. The patient had negative cardiac enzymes. The patient was given morphine and admitted. The patient was discharged (d/c) the next day with outpatient follow up. The treating provider prescribed therapy with inpatient (IP) hospital admission. The treating provider is requesting plan approval for inpatient (IP) hospital admission.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient hospital admission is not considered medically necessary for this patient.

This patient could have been managed in a lower level of care such as observational status on the date of service (DOS) in question. As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization was not medically necessary for the DOS in question. The patient could have received pain medications and been observed for low probability coronary artery disease (CAD) in observational status.
As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021).

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

Diagnosis: obstructive sleep apnea

Treatment: Oral Device/Appliance Custom Fabricated

The insurer denied coverage for Oral Device/Appliance Custom Fabricated

The denial is overturned

Upon review of submitted documentation which includes narrative reports and clinical progress notes, copies of sleep study results, and insurer correspondence, it appears that this patient with BMI (body mass index) 40.1 fatigue, snoring, and allergies, presented for recommendation on how to manage obstructive sleep apnea. The doctor recommended the oral appliance therapy as it was documented that the patient was/would be intolerant of the CPAP (continuous positive airway pressure) machine (as per the Affidavit). The insurer had denied the oral appliance therapy stating that the services is denied as the documentation provided and the clinical findings offered does not support/meet their medical necessity criteria and the is no documentation that CPAP was attempted. 

Based on the documentation provided, it is clear, based on the results of the sleep study, that the patient exhibits obstructive sleep apnea. Although CPAP therapy is considered the gold standard treatment for this condition, other therapies such as oral appliance therapy are accepted treatment modalities and FDA (Food and Drug Administration) approved in those cases in which CPAP is unable to be tolerated or no longer effective. In this case, the affidavit states CPAP could not be tolerated and therefore the oral appliance therapy was recommended, Peer reviewed literature (see below references) indicates that an oral appliance is an effective treatment for obstructive sleep apnea. Further, this patient does fulfill accepted clinical criteria for oral appliance therapy. As such the oral appliance therapy is considered medically necessary.

Overturned denial and approve coverage for an oral appliance, as medically necessary as it fulfills the standard criteria and is an accepted treatment modality in this clinical circumstance.

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

The insurer's denial of coverage for the Oral Device/Appliance Custom Fabricated is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: obstructive sleep apnea

Treatment: Oral Device/Appliance Custom Fabricated

The insurer denied coverage for Oral Device/Appliance Custom Fabricated

The denial is overturned

Upon review of submitted documentation which includes narrative reports and clinical progress notes, copies of sleep study results, and insurer correspondence, it appears that this patient with BMI (body mass index) 40.1 fatigue, snoring, and allergies, presented for recommendation on how to manage obstructive sleep apnea. The doctor recommended the oral appliance therapy as it was documented that the patient was/would be intolerant of the CPAP (continuous positive airway pressure) machine (as per the Affidavit). The insurer had denied the oral appliance therapy stating that the services is denied as the documentation provided and the clinical findings offered does not support/meet their medical necessity criteria and the is no documentation that CPAP was attempted. 

Based on the documentation provided, it is clear, based on the results of the sleep study, that the patient exhibits obstructive sleep apnea. Although CPAP therapy is considered the gold standard treatment for this condition, other therapies such as oral appliance therapy are accepted treatment modalities and FDA (Food and Drug Administration) approved in those cases in which CPAP is unable to be tolerated or no longer effective. In this case, the affidavit states CPAP could not be tolerated and therefore the oral appliance therapy was recommended, Peer reviewed literature (see below references) indicates that an oral appliance is an effective treatment for obstructive sleep apnea. Further, this patient does fulfill Milliman criteria for oral appliance therapy. As such the oral appliance therapy is considered medically necessary.

Overturned denial and approve coverage for an oral appliance, as medically necessary as it fulfills the standard criteria and is an accepted treatment modality in this clinical circumstance.

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

The insurer's denial of coverage for the Oral Device/Appliance Custom Fabricated is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polytrauma
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female who was struck by a semi truck at 50 miles per hour with injuries including: bilateral trace pneumothoraces, Grade II splenic laceration, and clavicle fracture requiring open reduction and internal fixation. . 

Yes, the proposed treatment was medically necessary.
The patient was involved in a serious accident that caused bilateral pneumothoraces, Grade II splenic laceration, and left clavicle fracture that required open reduction and internal fixation. Management of this polytrauma could not be managed at a lower level of care, and it would be unsafe to discharge the patient with follow up. All services in the medical record and the stay were medically appropriate to ensure that the patient's pneumothoraces did not worsen requiring thoracostomy tube placement or that the patient did not need intervention for her splenic laceration. Grade II splenic lacerations are usually managed non-operatively, but these usually do require close monitoring with complete blood count (CBC) checks and bedrest for greater than (>) 24 hours. Clavicle fracture was deemed by the orthopedic surgeon to medically necessary to be fixed inpatient. All these reasons meet medical necessity for inpatient admission.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
This patient's care at the inpatient level of care was medically necessary. The medical plan reason for stating that this was not necessary was because the patient did not have immediate surgery for life threatening injuries. The patient had serious injuries that needed inpatient monitoring to ensure that she did not develop a life threatening condition that required emergency thoracostomy tube placement or emergency laparotomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/Palpitations
Treatment: inpatient hospital stay
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a woman with a past medical history of anemia and palpitations who presented to the emergency department for evaluation of generalized weakness with facial paresthesia. She also reported associated chest pain and palpitations. On arrival to the emergency department (ED), she was afebrile, with a heart rate of 127 beats per minute, a blood pressure of 138/78 millimeters of mercury (mmHg), a respiratory rate was 18/minute, and she was saturating at 100% on room air. Initial labs demonstrated a white blood cell (WBC) count of 10, a hemoglobin of 10, a platelet count of 388, a sodium of 136, a potassium of 4.5, and a creatinine of 0.85. The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were within normal limits. A chest x ray did not demonstrate any acute cardiopulmonary abnormalities. An electrocardiogram (EKG) showed sinus tachycardia with non-specific T wave abnormality. Her troponin, brain natriuretic peptide, and D-dimer were all within normal limits. Her thyroid stimulating hormone (TSH) was 0.69. The patient was admitted to the inpatient unit for treatment of tachycardia which was thought to be secondary to anemia versus anxiety disorder. Her chest pain was thought to be due to "Gastrointestinal upset triggered by her iron pills." She was hydrated with intravenous (IV) fluids and given a history of menorrhagia, she was evaluated by gynecology, and they recommended an outpatient work up. Given low vitamin D levels, she was started on vitamin D supplementation. For her anxiety, she was given Xanax and was told to follow up with psychiatry as outpatient. She was ultimately discharged.
At issue is the medical necessity for the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

Admission to an inpatient level of care was not medically necessary. The patient presented with palpitations and paresthesias. On arrival, she was found to be tachycardic but afebrile. She was hemodynamically stable and there was no evidence of an acute infection. She did not have evidence of acute ischemia and/or arrhythmias on her EKG. The patient was ruled out for acute coronary syndrome by serial troponins. She did not have evidence of pulmonary embolism as supported by a normal D-dimer level. Although she had anemia, this was stable, and she did not require blood transfusions. Her hemoglobin was not less than 7. Consequently, based on the provided documentation, there is insufficient clinical data to support the medical necessity for an inpatient level of care. An alternate level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Superficial wound infection.
Treatment: Negative-Pressure Wound Therapy Pump.

The insurer denied a Negative-Pressure Wound Therapy Pump. The health plan's determination is overturned.

This case describes a female patient, who underwent primary right total hip replacement surgery. The patient suffered a superficial wound infection and underwent surgical irrigation and debridement. The patient then suffered a wound dehiscence and underwent additional surgery for a repeat irrigation and debridement and application of a wound vac. Repeat surgeries for irrigation and debridement and exchange of the wound vac were undertaken. The patient's health plan denied coverage for the wound vac.

The requested Negative-Pressure Wound Therapy Pump is medically necessary for this patient. The records document that this patient unfortunately suffered a severe wound complication and superficial infection with Morganella morganii. The patient appropriately underwent multiple would irrigation surgeries and application of a wound vac device for assistant wound closure. The documentation provided clearly demonstrates the medical necessity of the negative pressure wound therapy pump in this case.

The current, peer-reviewed literature, including articles published by Revesz and colleagues and by Jensen and associates documented the benefits off negative pressure wound therapy pumps for vac assisted wound closure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of falls, osteoarthritis, legal blindness, hypertension

Treatment is consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day: 84 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day: 84 hours per week
 
The denial is overturned

This is a female patient with a history of falls, osteoarthritis, legal blindness, and hypertension. The records submitted include the most recent document of a family member. There were reports of deterioration and lack of ability to perform activities. There is a report of several falls. These findings taken in context to the clinical situation would substantiate the need for additional care. There were no other clinical records submitted nor evaluations to deny necessity. 
There were records showing the person has reached maximal rehabilitation potential and required several durable medical equipment (DME's). Continued falls would likely lead to more serious complications which would warrant increased services.

The insurer did not act reasonably, with sound medical judgment or in the best interest of the patient. Medical necessity is substantiated.

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day; 84 hours per week is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain/sickle cell disease. 
Treatment: Inpatient stay. 

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

The patient is a male who initially presented to the emergency department with concerns for worsening chronic pain. Pertinent history included a previous admission for similar symptoms. Additional history included sickle cell disease with multiple complications including acute chest syndrome, priapism, left hip avascular necrosis (AVN), and opioid dependence. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. In this particular situation, the patient did not have evidence of acute chest syndrome but did have a presentation suspicious for a vasoocclusive crisis. For this reason, the patient should have been provided appropriate analgesia and monitored for response in observation. Following observation care, the patient's presenting symptoms were controlled and he was discharged. No other issues or complications were documented. 
In regards to inpatient level of care, clinical indications were not met. The patient did not have signs or symptoms of central nervous system acute injury, acute chest syndrome, hypoxemia, emergent surgery needed, splenic or hepatic sequestration, acute ischemia, acute renal failure, aplastic crisis, priapism or other vascular complications, traumatic hyphema, infection requiring inpatient treatment (eg, bacteremia), altered mental status, need for exchange transfusion, inability to maintain oral hydration despite observation care treatment, or pain insufficiently responsive to observation care treatment that requires treatment in inpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is overturned

This is a patient that presented to the hospital complaining of chest pain and shortness of breath. Past medical history was significant for diabetes mellitus and hypertension. Upon arrival, the patient was tachycardic with a pulse of 126 bpm (beats per minute). Blood pressure was stable (136/74 mmHg (millimeters of mercury)). Physical exam revealed tachypnea and an irregularly irregular rapid pulse. Serum blood testing was significant for hyperglycemia (222 mg (milligrams) /dl (deciliter)). A 12-lead electrocardiogram (ECG) revealed atrial fibrillation with a ventricular rate of 127 and no ischemic ST (interval on a ECG) or T (interval on a ECG) wave abnormalities. The patient was treated with AV (Atrioventricular) nodal blocking agents (IV (intravenous) diltiazem) and admitted to the hospital. An echocardiography revealed an LV (left ventricular) ejection fraction of 45%. The patient was ultimately treated with metoprolol therapy and discharged.

Admission for monitoring and treatment was medically necessary. 

Patients presenting with atrial arrhythmia with ventricular rates up to 127 bpm require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. American Heart Association/American College of Cardiology Guidelines for the management of patients with atrial fibrillation recommend telemetry monitoring for patients treated with atrial fibrillation requiring treatment with rate control and antiarrhythmic therapies. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation.  In conclusion, inpatient admission was medically necessary in this case. 

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.