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

Central Nervous System/Neuromuscular Disorder - Other
Inpatient Hospital

The patient is a female with a history of hypertension, hypothyroidism, fatty liver, and depression. Very early in the morning she presented to the emergency room several hours after experiencing lightheadedness and near syncope when she got out of bed. In addition, she noted a perioral tingling, which resolved shortly after arriving at the hospital. The vital signs and physical exam, including the neurologic exam, were normal. Labs were non-contributory. The computed tomography (CT) scan was negative for an infarct but showed a "Questionable 4 millimeter (mm) left parietal vague hyperdensity versus artifact". The electrocardiogram (EKG) was negative as well. The neurology consultant evaluated the patient and concluded that the patient did not have a transient ischemic attack (TIA), her symptoms were mostly likely due to a transient blood pressure (bp) pressure drop (perhaps vasovagal), and the CT scan finding was an artifact. No further tests or treatment were recommended. Regardless, the patient was admitted for further evaluation and treatment.
Upon admission to a monitored bed, the patient was treated with an aspirin, a statin, and her usual levothyroxine. The hospital course was clinically uneventful, and she was discharged later that day.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. There was no credible evidence that the patient suffered a TIA. Based on the standard of care and peer reviewed literature, the inpatient level of care was not medically necessary, and the patient could have easily and safely been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient admission.

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

The patient is a female.  The patient has a past medical history significant for gout, uterine cancer, s/p (status post) resection, alcohol abuse, psychiatric disease, tobacco abuse.  She presented to the ER for complaints of left hip pain and left chest pain.  The chest pain was described as non-exertional, with no radiation, no associated shortness of breath, syncope or palpitations.  She was hemodynamically stable.  The patient was also found to have ethanol intoxication.  Her ECG (echocardiogram) was unremarkable.  There was no significant troponin elevation. 

The patient was admitted to rule out acute coronary syndrome.  Echocardiogram was done, revealing normal LV (left ventricle) systolic function with no wall motion abnormalities.  A stress test revealed no inducible ischemia.  The patient was started on antibiotic therapy for abdominal wound infection.  She was discharged home with a plan for outpatient follow-up.

No, the proposed Inpatient admission is not "medically necessary".

This patient presented for evaluation of hip pain and chest pain.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, and the patient was referred for a nuclear stress test.  Ischemia was ruled out by stress testing.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  The patient was treated with antibiotic therapy for local wound infection and was discharged home on oral antibiotic.  The clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, dizziness 
Treatment: Inpatient admission 

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

The patient is a female at the time of admission to the hospital. The patient has a past medical history significant for anemia. She presented to the ER for evaluation of dizziness, chest discomfort, headache, and right shoulder weakness. The patient was hemodynamically stable. ECG (echocardiogram) was unremarkable.  A head CT (compute tomography) scan revealed no acute intracranial pathology. The patient was admitted to telemetry for monitoring. There were no orthostatic changes. Her cardiac troponins were negative. She was seen in consultation by neurology. She was treated with oral meclizine. An echocardiogram was obtained, which revealed normal LV (left ventricle) systolic function. Carotid Doppler was unremarkable. She was discharged home with a plan for outpatient follow-up. 

No, the proposed inpatient admission  is not "medically necessary". 

This patient presented for evaluation of dizziness and atypical chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. No inpatient ischemic work-up was planned. Echocardiogram was unremarkable. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. There was no evidence of a CVA (cerebrovascular accident), TIA (transient ischemic attack), seizure, intracranial bleeding or any acute neurological event. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse/Addiction substance abuse/addiction 
Treatment: Substance Abuse /Inpatient. 
The insurer denied the inpatient substance abuse stay  . 
The denial is upheld in whole .

The patient, who presented with a request for detoxification treatment and was medically screened and admitted to inpatient level services for detoxification of alcohol; and was also using crack cocaine .
No, the requested health service/treatment of Inpatient Detoxification and Withdrawal Management services is not medically necessary for this patient. The requested benefit of detoxification treatment, and other services to address the substance use disorders, could have been safely and effectively provided with lower level services. This is consistent with prevailing standards of medical practice in this case scenario. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community.
Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature, as well as NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines., Therefore the inpatient level treatment for alcohol and cocaine use disorders could have been effectively provided with a lower level care, medical necessity is not met in this case for inpatient level treatment .
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 with no significant medical history.  He presented to the Emergency Department (ED) with complaints of an insect bite to his left lower leg.  The patient's vital signs on ED presentation included: temperature 98.5 F, blood pressure 117/73, pulse 81, respiratory rate 18, and oxygen (O2) saturations100% on room air.  The patient's laboratory values were notable for the following: white blood cell (WBC) count of 10.5, hemoglobin of 15, hematocrit of 45.4, creatinine of 0.82, ESR of 4, CRP of 0.70, and lactate of 1.0.  The patient was admitted for cellulitis of the left lower leg following an insect bite.  The patient received antibiotics (i.e. vancomycin and cefazolin) while in the ED.  The patient's imaging studies were negative.  Infectious Diseases was consulted and they recommended switching the patient to oral antibiotics.  The patient remained afebrile, hemodynamically stable, and clinically improved.  The patient was discharged to continue with oral antibiotics as an outpatient.

Based on the review of the medical record and the literature, inpatient admission was not medically necessary for this patient.  The patient was admitted with a possible lower extremity cellulitis.  Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results.  There was no evidence of a disseminated infection.  The patient was able to tolerate oral intake, and no surgical intervention was required.  Based on these findings, the patient did not meet the clinical criteria for acute care hospitalization.  The health plan acted reasonably with sound medical judgment.

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

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was reversed.

This is a female patient with a history of asthma. He presented to the emergency department (ED) after being found in the street drowsy and with pin point pupils. The patient reportedly took some Percocet tablet for a tooth ache. The patient responded to Naloxone in the field and was brought to the ED. In the ED the patient was initially awake but started getting drowsy again as time progressed. The patient further complained of fevers, myalgia, cough and some hemoptysis. Vital signs:  temperature 102.8 F, heart rate 124, blood pressure 107/69 mm Hg, and oxygen (O2) saturations were 90%. The patient's lung exam revealed bilateral rales. The patient was awake and alert, but her mental status was waxing and waning. A laboratory work up was performed and revealed a white blood cell count was 9.2 K, Hb 11.5, AST 68, ALT 129. An electrocardiogram (EKG) was done and revealed sinus tachycardia. Influenza B test was done with positive results. Urine toxicology was positive for Cannabinoids. Chest x-ray revealed multi-lobar pneumonia. A computed tomography (CT) angiogram was done that revealed bilateral pneumonia involving multiple lobes; the study was sub optimal.

This patient had a multi-lobar pneumonia, was febrile and had waxing and waning mental status. The patient was hypoxic with O2 saturations 90%. PE had not been definitively ruled out. The patient was placed on Lovenox and VQ scan and deep vein thrombosis study planned. The patient received intravenous (IV) antibiotics for possible community acquired pneumonia vs aspiration pneumonia.

This patient had multiple medical issues and was not stable enough to be managed in observation status. Her needs were more acute and admission was appropriate. The health Plan did not act reasonably with sound medical judgment 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: Overturned

Diagnosis: Cellulitis, Abscess
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was overturned.

This is female patient with immunocompromised status and a past medical history significant for substance abuse and depression. The patient presented to the Emergency Department (ED) with complaints of right ankle swelling and erythema.  The patient's vital signs on presentation were: temperature 98.2 F, blood pressure 147/76, pulse 86, respiratory rate 20, and oxygen (O2) sat-99% on room air. The patient's laboratory results included the following: white blood cell (WBC)-11.4, hemoglobin-11.6, hematocrit-36.3, creatinine-0.91, glucose-167, ESR-69, CRP-1.1, and urine toxicology positive for cocaine and opiates. The patient was admitted to the hospital for cellulitis/abscess of the right ankle; she received intravenous (IV) antibiotics. Surgery was consulted and an incision and drainage (I&D) was performed. The patient's wound culture grew methicillin-resistant staphylococcus aureus (MRSA). The patient refused magnetic resonance imaging (MRI). The patient received wound care. The patient had an episode of hypotension prior to signing out against medical advice (AMA).  

According to medical record, the patient presented with a right ankle abscess. The patient's laboratory results showed elevated white blood cell (WBC) count, anemia, and increased ESR. The patient's urine toxicology was positive for substance abuse. Based on these clinical findings in a high-risk patient with immunocompromised status, inpatient admission was medically necessary for administration of intravenous antibiotics and surgical intervention.    

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 admission is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied the inpatient stay.
The denial is overturned.

The health plan's determination of medical necessity is overturned.
The patient presented with severe rectal pain and an acute onset of bleeding, nausea, and diarrhea. On exam the patient was noted to have thrombosed external hemorrhoids. A computed tomography (CT) scan of the pelvis also showed mild rectal wall thickening and possible hemorrhoids. The patient was hospitalized. The patient was prepped for gastrointestinal (GI) procedures, underwent an esophagogastroduodenoscopy (EGD) and colonoscopy. The patient underwent a magnetic resonance imaging (MRI) which did not demonstrate evidence of a perianal fistula. The patient had several episodes of blood with bowel movements up until this point. The patient underwent an excisional hemorrhoidectomy and suture ligation of other hemorrhoids. The patient had a fever to 101F. and blood cultures, a complete blood count (CBC) and procalcitonin were checked, and the patient was started on Flagyl. The patient was discharged home. At issue is the medical necessity of the inpatient stay.

Yes. The requested inpatient stay was medically necessary for this patient. The patient presented with symptoms of gastrointestinal bleeding and severe rectal pain. The patient also received treatment for hypotension which represented mild hemodynamic instability. Overall the patient received a high level of monitoring, multiple diagnostic procedures and tests in rapid succession, which combined with the intervention required to stop the bleeding necessitated an inpatient level of care. This patient presented with severe rectal pain and an acute onset of bleeding, nausea, and diarrhea.The patient had several episodes of blood with bowel movements. The patient underwent an excisional hemorrhoidectomy and suture ligation of other hemorrhoids. The patient had a fever to 101F and blood cultures, a complete blood count (CBC) and procalcitonin were checked, and the patient was started on Flagyl.

The patient's gastrointestinal bleeding meets Milliman Care Guidelines (MCG) guideline criteria, as it is ongoing active bleeding as recurrent hematochezia and failure to control bleeding after a colonoscopy. The patient meets several of the indications for inpatient admission per the MCG guidelines for Gastrointestinal Bleeding and in addition utilized monitoring, diagnostic procedures, and interventions which necessitated an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse 
Inpatient Hospital 

Diagnosis: Alcoholism 
Treatment: Inpatient stay 

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

The patient is a woman with a history of diabetes, hypertension, asthma, seizures, alcohol abuse, and cocaine abuse who presented to the hospital with a chief complaint of requesting alcohol detox. She reported that she had experienced seizures previously when withdrawing from alcohol. She stated that she drank 12 cans of beer a day and also consumed liquor. In addition, she reported chronic hand and foot pain. She denied nausea and vomiting. Vital signs showed temperature 98.5 Fahrenheit, heart rate 82, blood pressure 120/75, and oxygen saturation 99%. On physical examination, heart was regular, breath sounds were normal, abdomen was soft and nontender, and there were no focal neurologic deficits. 

The inpatient admission was not medically necessary. The patient presented for alcohol withdrawal, but she was hemodynamically stable and had a low Clinical Institute Withdrawal Assessment (CIWA) score at the time of admission. She did have a prior history of possible seizures in the setting of alcohol withdrawal, but patients with alcohol withdrawal do not routinely need to be managed at the inpatient level of care when they present with few symptoms because early benzodiazepine therapy significantly reduces withdrawal severity. Given her stability at the time of presentation and the absence of other significant findings such as sepsis, active seizures, stroke, or myocardial infarction, the patient could have safely and effectively been managed at a lower level.
Appeal type: Medical necessity
Decision: Overturned in Part

Schizophrenia
Inpatient Mental Health

The patient is a male with a diagnosis of paranoid schizophrenia (PS). Case notes document that the patient has suffered from chronic severe PS requiring multiple past admissions. Two days before the admission under review, he was referred to the Methodist Hospital and released after evaluation. His admission by emergency services was due to agitation and aggression, and the abnormal behavior of trying to burn down his residence out of anger. On initial evaluation, he was floridly manic and uncooperative, irritable and unkempt, with suicidal ideation (SI) and auditory hallucination (AH).

The health plan's determination is overturned in part. Inpatient mental health was indicated for 11 days. After day 11, the patient could have been cared for at a lower level of care. The remaining 45 days would not be medically necessary. 

For example, the patient was still poorly groomed. His ADLs (activities of daily living) were poor. He had poverty of speech. He was paranoid, delusional, with poor insight and judgment. He continued to be poorly groomed, with continued poverty of speech. He was judged to be at risk for readmission if discharged. Distinct improvement was noted. The patient said he felt fine. He was euthymic and calm. He had no SI or HI. He was experiencing no auditory hallucinations. His affect was still flat, however. He was started on IM depot risperidone Consta. On day 11, he was judged to be at his baseline. He was compliant with his meds. He showed no abnormal behaviors. He continued to be euthymic. Therefore, he could safely and with good medical judgment be discharged to a less intensive level of care.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal - Other
Pharmacy/Prescription Drugs

This patient is a female with a history of psoriatic arthritis (PsA). Per review of the file, the patient had prior treatment with Enbrel, to which the patient had a severe injection site reaction, Cosentyx, which the patient tried and failed, and Humira, which she was on and it was not effective; and she has failed Stelara, Otezla, Xeljanz, Remicade, Orencia, methotrexate (MTX), and Aleve. At issue is the medical necessity of the requested treatment with Simponi Aria. 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of Simponi Aria is medically necessary for this patient. She has tried and failed or has had an adverse reaction to all the formulary medications, including Cosentyx, Enbrel, Humira, Stelara, Otezla, Xeljanz, Remicade, Orencia, and MTX. It is medically necessary to try Simponi Aria currently for the treatment of her PsA.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Celiac disease and intestinal metaplasia 
Treatment: 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple) 

The insurer denied coverage for 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple). The denial is reversed. 

This patient is a female diagnosed with both celiac disease and intestinal metaplasia in the gastric antrum on biopsies performed during endoscopy a few years ago. The patient had been on a strict gluten-free diet and her symptoms have improved. 

According to UptoDate article on gastric intestinal metaplasia, endoscopic surveillance with gastric biopsies is advised for this patient. Literature evidence suggests that surveillance may lead to early detection of gastric cancer and improved survival. However, the optimal surveillance interval has not been fully determined. UpToDate article on "Management of celiac disease in adult" states that the consensus is that re-biopsy should be undertaken after commencing a gluten-free diet to confirm a satisfactory response to the diet. 

This patient had two conditions which required careful follow up. Both intestinal metaplasia and celiac disease diagnoses increase this patient's risk for malignancy, and a close follow-up with endoscopic monitoring was medically necessary. 

Thus, esophagogastroduodenoscopy (EGD) with biopsy was medically necessary to properly monitor and treat this patient's medical condition. 

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

The carrier's denial of coverage for procedure Code 4323 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple) is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adverse Food Reaction
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with hypertension and diabetes who presented with allergic reaction to cashews. The patient was found to have swelling of her face and neck and was having difficulty breathing. 

The patient received intravenous (IV) steroids, Benadryl and Pepcid. The patient was also found to have hypertensive urgency and received IV hydralazine.  The patient was admitted to acute in hospital level of care. The patient's condition partially improved with emergency room care and due to severe facial swelling and high blood pressure, the patient was admitted to intensive level of care. The patient was on oral prednisone. The patient was tolerating oral diet. The patient's blood pressure was better controlled.

No, the proposed treatment was not medically necessary.

The patient had a severe episode of angioedema due to cashews and also had a hypertensive emergency. The patient improved significantly with emergency room care and was able to eat, drink and take oral medications as well as had better blood pressure control.  The entire admission was not medically necessary. The patient could have been safely and effectively treated as an observation level of care with outpatient follow up.