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

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

This is a male patient, with a past medical history of hypertension and alcohol abuse, who presented with a squeezing chest pain rated 5/10, without radiation, which started at rest. He denied various symptoms, including a fever, chills, gastrointestinal issues, headache, neurological symptoms, weakness, tingling, dysuria, hematuria, palpitations, and diaphoresis. His troponin levels were elevated at 25, and an electrocardiogram revealed T-wave abnormalities, leading to the administration of Aspirin.
The patient was subsequently transferred for further management. The troponin continued to rise, reaching 26.1. A transthoracic echocardiogram was performed and revealed an ejection fraction of 55-60 percent (%). The patient left against medical advice, for an unspecified reason, but returned later to continue the workup.
The review of systems was obtained at the time of admission and demonstrated increased urinary frequency due to incomplete bladder emptying, with the rest being negative.
The patient was admitted to the hospital with unspecified chest pain and an elevated troponin to rule out acute coronary syndrome. Additional clinical diagnoses included hypertension, chronic kidney disease secondary to hypertensive nephrosclerosis, benign prostatic hyperplasia, a history of alcohol abuse, microscopic anemia, and vitamin D deficiency.
During the hospital stay, the patient underwent a stress test that revealed no evidence of reversible ischemia, and the left ventricular ejection fraction was found to be 50%. The cardiology service evaluated the patient and recommended no further cardiac evaluation.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with chest pain which was not associated with hemodynamic instability or respiratory distress. There was no clinical evidence that the patient had angina or myocardial infarction. The elevation of troponin levels was most likely due to chronic kidney disease and not cardiac issues.
The chest pain was not indicative of a serious diagnosis other than coronary artery disease.
The review of medical records demonstrated that the services could have been provided at the observation level of care since neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. 
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

Thia is an adult with a history of cardiac disease and diabetes who presented for evaluation of abdominal pain. The patient was afebrile, and the vital signs were stable. There was abdominal tenderness but no rebound or guarding. A computed tomography (CT) scan was read as stable size and shape with a suggestion of minimal developing haziness around the pancreatic body, raising the possibility of minimal pancreatitis, enzyme correlation suggested. The patient's lipase was 520 (reference range 23 to 300). Pain medications and intravenous fluids were given. The patient's diet was able to be advanced. 

Medical necessity was determined based on Milliman Care Guideline (MCG) guideline M-250 for Pancreatitis. Clinical indications for admission include having acute pancreatitis as manifested by 2 of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and a finding on imaging of pancreatic inflammation, pancreatic necrosis, or a peripancreatic fluid collection indicative of acute pancreatitis.
 
This patient had abdominal pain but did not have a lipase greater than 3 times the upper limit of normal. The computed tomography (CT) scan did not show acute pancreatitis. It was read as a suggestion of minimal developing haziness around the pancreas. This was not a definitive reading of acute pancreatitis. In addition, the patient did not have evidence of infection, hemodynamic instability, severe vomiting, acute renal failure, altered mental status, or severe electrolyte abnormalities. 
 
The patient had mild pancreatitis and the symptoms rapidly improved. The patient could have been managed with observation status. Milliman Care Guideline (MCG) guideline criteria for admission for pancreatitis were not met.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Anemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is overturned

The patient presented to the emergency department (ED) with complaint of symptomatic anemia including syncope and dizziness. 

The patient received 2 units of packed red blood cells (PRBC's) and Provera. The appealer writes that the patient met MCG (Milliman Care Guidelines) Anemia, Iron Deficiency criteria for an inpatient admission and it was medically necessary.

The insurer has denied coverage for an inpatient admission. In their Final Adverse Determination letter, they write that the patient had dizziness and low blood count. The patient was not unstable. The patient did not have unstable vital signs that did not improve, active severe bleeding with high-risk features, severe pelvic infection, abdominal infection, or the need for open surgery. The insurer writes that the patient did not meet MCG (Milliman Care Guidelines) Obstetric and Gynecologic Disease 26th edition criteria for inpatient admission and it was not medically necessary.

This patient fulfills the transfusion guidelines for use of blood components: the patient's hemoglobin was less than 8. Transfusion was necessary. It is obvious that in this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission. However, the patient was symptomatic. In addition, the patient had an episode of syncope.

MCG lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, and syncope. 

Based on all of the above, admission was medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Endocrine
Pharmacy/prescription drug

Diagnosis: diabetes
Treatment: Mounjaro
The insurer denied Mounjaro
The health plan's determination is upheld. 

The patient is a male being prescribed to Mounjaro for the diagnosis of type 2 diabetes mellitus. The health plan denied coverage for the medication because it is not on the plan formulary and there are other medications in the same class which have not been tried in the patient. Formulary alternatives available to treat the patient's condition include Trulicity and Victoza.

A formulary exception is not indicated in this case. The patient has had a trial of one of the medications in the GLP-1 (Glucagon-like peptide-1) agonist class, Ozempic. He has not tried the other available medications in this class (Trulicity and Victoza). There is no contraindication or necessity for bypassing trial of these formulary medications. There is currently no head-to-head trial data suggesting the superiority of the requested medication over the formulary alternatives. Because all of these medications work via a similar mechanism of action, there is insufficient evidence that the formulary medications would have more adverse effects than the requested medication. Therefore, there is insufficient medical justification for the approval of the non-formulary drug over the available formulary alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient hospital stay
the insurer denied the inpatient hospital stay.
the health plan's determination is overturned. 

The patient is a male with a history of asthma who presented with dyspnea, cough productive of green phlegm, and wheezing after an emergency department (ED) visit 4 days prior for similar symptoms during which time he received steroids and nebulizers and was discharged home.

In the ED, temperature was 98.1, blood pressure (BP) 138/92, heart rate (HR) 92, respiratory rate (RR) 18, and pulse oximetry 95% (percent) room air (RA). The patient was alert and oriented, and heart was regular. He had increased work of breathing with diffuse wheezing, alert and oriented. White blood cell (WBC) count was 8.9, Na (sodium) 142, bicarbonate 28, Blood urea nitrogen (BUN)/Creatine (Cr) was 19/1.1. Venous blood gas (VBG) was 7.33/57. The chest x-ray (CXR) clear. His symptoms persisted despite intravenous (IV) steroids, nebulizers, and magnesium.

An inpatient admission was medically necessary. The patient presented with dyspnea, cough, and wheeze and was diagnosed with an acute asthma exacerbation. While he was not severely ill at presentation, he had failed outpatient treatment with worsening symptoms despite oral steroids, antibiotics, and inhalers. This meets inpatient criteria. In addition, persistent symptoms despite routine care raises the risk for either a severe flare with increased risk of worsening or needing Intensive Care Unit (ICU) care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronavirus 2019 (COVID-19)
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient is a male with a history of asthma who presented to the emergency department (ED) with concerns of a cough, body aches, and wheezing in the setting of a recently positive coronavirus 2019 (COVID-19) test. COVID-19 polymerase chain reaction (PCR) was positive. An electrocardiogram (EKG) revealed sinus tachycardia with no acute ischemic changes. A chest x-ray (CXR) did not reveal acute cardiopulmonary disease. Dexamethasone, nebulizers, and intravenous fluids were provided. The patient was admitted to the hospital. The admitting physician documented the patient as breathing comfortably on room air without wheezes. The initial impression included COVID-19 infection, hypokalemia, hypomagnesemia, and asthma without shortness of breath or wheezing. The treatment plan included electrolyte replacement, oxygen saturation monitoring, and consultations. Hemodynamics were stable and without hypoxia. Hypokalemia and hypomagnesemia resolved. Oral Paxlovid was administered for the COVID-19 infection, otherwise treatment was unchanged. The oral Paxlovid course was completed and the patient was discharged. Based on the clinical documentation provided, evidence-based literature, and standard of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient had a history of asthma who presented with concerns of cough, body aches, and malaise after testing positive for COVID-19 infection. Initial examination documented the patient as afebrile, alert, oriented, hemodynamically stable, and without hypoxia. Initial evaluation was relatively unremarkable with the exception of hypokalemia and hypomagnesemia. A chest radiograph did not reveal an acute cardiopulmonary process. Following ED care, the patient was breathing comfortably on room air without wheezes. Treatment thereafter included oral Paxlovid and supportive care. Following observation care, the patient remained afebrile, hemodynamically, without hypoxia and with resolution of electrolyte abnormalities. No other issues or complications were documented.

Clinical indications for admission to inpatient care were not met. The patient did not have impending or actual respiratory arrest, severe airflow or ventilation abnormalities not responsive to emergency and observation care treatment, severe respiratory findings not responsive to emergency and observation care treatment (e.g. ["for example"] hypoxemia, severe tachypnea, accessory muscle use, respiratory retractions), hemodynamic instability, severe or persistent dehydration, inability to maintain oral hydration, severe or persistent altered mental status, acute kidney injury, or cardiac arrhythmias of immediate concern. [2, 3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: shortness of breath 

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult female with end stage renal disease (ESRD) who admitted for shortness of breath due to volume overload and hypertension due to missing dialysis treatments. She was evaluated by nephrology and underwent dialysis treatment for clearance and volume removal. Her condition improved with ultrafiltration, and she was discharged in stable condition.

Patient was admitted with volume overload, she was treated with hemodialysis and intravenous blood pressure medication on admission. Her condition responded to daily dialysis, she did not have persistent severe hyperkalemia, no ongoing signs of severe volume overload or hypoxia, no documentation of severe uremia such as encephalopathy or uremic bleeding.

She had established dialysis access and did not require emergent vascular intervention.
Her condition could have been treated safely at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: leg weakness
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female who presented with left leg weakness and numbness after falling asleep with her leg dangling off the bed in the setting of cocaine and alcohol abuse.
In the emergency department (ED), temperature was 98.4, blood pressure (BP) 97/55, heart rate (HR) 90, respiratory rate (RR) 18, and pulse oximetry 95% room air (RA). She was in no distress, heart regular, breathing comfortably, alert and oriented, with motor and sensory deficits noted in left leg. White blood cell count (WBC) was 19.7, Na (sodium) 139, bicarb 24.9, blood urea nitrogen (BUN) /Cr (creatinine) 22/0.86, procalcitonin 3.78; tox screen positive for cocaine, negative for alcohol. 

The inpatient hospital admission was not medically necessary.
The patient presented with left leg numbness and weakness that, before she was admitted, was already determined to be a non-surgical, non-emergent issue with only conservative management needed. She also was diagnosed with aspiration pneumonia but only had cough and phlegm, no dyspnea and no evidence of severe sepsis. The scoring systems would suggest a low risk of worsening or needing Intensive Care Unit (ICU) care. A Clinical Institute Withdrawal Assessment (CIWA) protocol was started, but she never scored to require treatment and did not experience alcohol withdrawal. Her left leg weakness and numbness improved within an observation care time frame and she was felt ready for discharge with home treatments within this time frame as well. Her respiratory symptoms also improved within this time frame. Given the low severity of illness, lack of concerning or emergent diagnoses, low risk of worsening, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Laparoscopic hysterectomy.
Treatment:  Inpatient stay.

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

The patient is a female who underwent a laparoscopic hysterectomy that was converted to an open total abdominal hysterectomy. The surgery was converted to an open hysterectomy due to multiple large fibroids obstructing visualization of the anatomy. The procedure, done for multiple symptomatic fibroids, was reported to have been completed without complication. 

The inpatient hospital stay was medically necessary.

An inpatient stay for this patient after open hysterectomy is medically necessary. The standard for such a surgery is a two day stay in the hospital (some literature puts the average at 3 days), commanding an inpatient level of care. The procedure is reported to be performed via a Pfannenstiel incision (a lower transverse incision, usually 10-14 centimeter [cm] wide), rather than a mini-laparotomy or laparoscopic approach. These incisions generate a significant amount of pain, requiring medication and nursing assistance that just cannot be provided at home. In addition to pain issues in these open cases, nausea is also common. Nausea poses a significant threat to the ability to take medication, as well as need for hydration. Open procedures carry higher risks of wound complications, thrombotic events, postoperative bleeds, and cardiopulmonary events.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain/shortness of breath
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female who had a history of hepatectomy for a large neuroendocrine metastasis. Upon admission, the patient complained of chest pain, shortness of breath, and constant abdominal discomfort, with distention persisting for at least 2 months. Occasional nausea and shortness of breath were reported, but no vomiting, fever, chills, blood per rectum, black stools, weight loss, jaundice, or icterus.

Inpatient hospital admission was not medically necessary. The patient presented to the hospital with nonspecific symptoms, which were most likely related to the progression of the neuroendocrine tumor. Having said that, the patient did not need any tumor-specific treatment during the hospital stay. There was no evidence that the patient had any significant respiratory complications, significant dehydration, significant electrolyte abnormalities, intractable nausea or vomiting, or inability to eat.
There was no evidence of tumor-specific complications including bronchial obstruction, respiratory distress, urinary tract obstruction, gross hematuria, refractory hypoglycemia, or active bleeding. The chest pain that the patient experienced at the time of admission was nonspecific and was unlikely related to cardiac origin. The hospital admission was relatively short and neither the severity of the patient's condition nor the complexity of services provided rose to the acute inpatient level of care.
Therefore, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has cirrhosis and underwent an orthotopic liver transplant (OLT). The patient has chronic kidney disease (CKD) and became hypertensive after computed tomography (CT) scan imaging was done. The patient had a blood pressure of 215 over 116 (215/116). The patient was having abdominal pain and diarrhea for a month. The patient required urgent treatment for hypertension. Afterwards, the blood pressure came down to 141/76. There was no abdominal rebound or guarding. A CT scan showed possible colitis. The blood pressure medications required being adjusted. Stool testing was done. Hyperkalemia was treated in the emergency room (ER) and improved. The liver enzymes were normal as well as the international normalized ratio (INR). 

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Care Guidelines [MCG] M-05) include hemodynamic instability, peritoneal signs, bowel perforation or obstruction, inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

Clinical indications for admission for Hypertension (MCG M-197) include having hypertensive emergency with one of the following: hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial infarction, acute renal failure, papilledema, and seizures. The patient did not have these conditions. The patient had chronic renal failure, not acute renal failure. 

This patient had a liver transplant but it was functioning normally. The patient required a workup for abdominal pain but this could have been done as an outpatient. The patient also developed hypertension after a CT scan and required urgent treatment. This treatment could have been given with observation status. The patient did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Hypertension. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

The denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.