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

The patient  presented with symptomatic left lower extremity varicose veins. The symptoms include pain, cramps and swelling of the left leg. Patient has attempted and failed conservative therapy with graded compression stockings without symptomatic relief. The patient underwent endovenous ablation of left great and small saphenous vein as well as stab phlebectomies of left lower extremity. The health plan's determination is overturned in part.
The endovenous ablation of the left great saphenous vein is Medically Necessary based on the peer reviewed literature. The left leg stab phlebectomies are Medically Necessary based on the peer reviewed literature, however, the endovenous ablation of the left small (lesser) saphenous vein, is not Medically Necessary because there is no evidence of reflux in this vein on the preoperative lower extremity venous duplex scan. The current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic brain injury, pseudobulbar affect, headaches, and nausea and dizziness

Treatment: Medication-Nuedexta

The insurer denied coverage for Nuedexta. The denial was reversed.
This is a female patient with a history of traumatic brain injury due to a motor vehicle accident. The submitted documentation detailed that the patient has been recommended to utilize the requested Nuedexta for pseudobulbar affect. The patient was seen for a follow-up. The documentation detailed that the patient was rear-ended while stopped. She was pushed into the car in front of her and her car was totaled. She has struggled with frequent and often debilitating headaches, as well as nausea and dizziness with the inability to concentrate. She also has sensitivity to lights and sound, and has memory issues. The patient also complained of limited range of motion to her right shoulder. The patient has had treatment with rizatriptan, Naprosyn, ibuprofen, diclofenac, Lamictal, Cymbalta, and gabapentin. She has also utilized medical cannabis for chronic pain and has had a previous cervical spine fusion. The physical examination revealed the patient was in mild distress. The patient did have trigger points in the trapezius bilaterally with decreased range of motion to the neck. Neurologically, she was alert and oriented.  
The documentation does detail that the patient did undergo a trial with the recommended Nuedexta with significant improvement. She stated she had less bouts of crying and inappropriate laughter. On examination, the patient's mood did seem to be more stable. The physician also detailed the patient scored a 21 on the Center for Neurologic Study-Lability Scale for pseudobulbar affect. It was recommended that the patient continue with medications and additional Nuedexta samples were given.
	
Given the documentation detailed, the patient has the appropriate diagnosis and has had prior treatment with improvement. The utilization of the requested Nuedexta is medically necessary and would be considered a standard of care medication option for this patient. Therefore, the previous denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High blood sugar during pregnancy
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.
The major acute issue was gastroenteritis, but the patient was documented to be tolerating oral intake.  Blood sugars and blood pressures were not in a life-threatening range, and there was no evidence of diabetic ketoacidosis or preeclampsia with severe features.  Laboratory abnormalities were relatively minor or chronic and were not in a range that required hospital admission.  Therefore, there is no evidence of medical necessity that would justify hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pervasive Developmental Disorder
Issue under review: Extended outpatient psychotherapy sessions

Determination:
The extended outpatient psychotherapy sessions are medically necessary.

The patient has a complex psychiatric and neurological condition.  There is profound dysfunction, both objectively and subjectively.  The patient has been unable to successful utilize standard of care shorter sessions, and she has found success utilizing longer sessions.  Her psychiatrist explicitly documented medical necessity of the treatment.

The patient has a complex psychiatric and neurological condition that is causing profound dysfunction.  She is receiving evidence-based care by licensed practitioners with expertise in the relevant fields.  She has been unable to successfully improve her symptomatology and functioning with standard of care treatment, but she has seen success with extended treatment sessions.  Her psychiatrist documented medical necessity, as well as the risks of stopping this treatment.  Therefore, the treatment should be covered by her health plan.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with impacted teeth number (#) 6, #11, and #27. The patient presented with a skeletal Class I malocclusion and significant crowding and is treatment planned for braces with palatal expansion to address the crowding and impacted teeth. The health plan's denial of medical necessity is overturned in whole. If left untreated, the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. Therefore treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Apnea
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

BRUE, or brief resolved unexplained event, has replaced the term ALTE, or acute life-threatening event. It is defined as brief self-resolved event occurring in an infant less than a year of age, associated with one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone; and/or altered level of responsiveness. BRUE is a diagnosis of exclusion. Infants that present for evaluation can be categorized as either high risk or low risk, based on careful and detailed history and physical exam. Any abnormalities on exam may place the infant into a higher risk category, with consideration for child abuse if there are inconsistencies in the story or exam, cardiac arrhythmia in the presence of positive family history, and infection if there is fever. To be considered lower risk, the infant must be older than 60 days, gestational age greater than or equal to 32 weeks and postconceptional age greater than or equal to 45 weeks, this must be the first event, the event must have lasted less than a minute, not requiring CPR, with no concerning historical or exam findings. 

While hospitalization overnight or longer for monitoring and evaluation may not be indicated for lower risk infants, hospitalization and further testing may be indicated for high risk infants. Concerning signs that would warrant hospitalization include toxic appearance, lethargy or respiratory distress at the time of the event, bruising or other evidence of trauma, history of multiple events in the past 24 hours, history of clinically significant events or unexpected death of a sibling, history that raises suspicion for the possibility of child maltreatment, and dysmorphic features or known syndrome.

This baby had an episode consistent with a brief resolved unexplained event (BRUE, previously known as an ALTE), and had recovered by the time she presented to the ED. By the criteria above, she would be considered low risk, but with her history of gastroesophageal reflux disease, there was sufficient concern to prompt further monitoring in the hospital setting. However, she was overall hemodynamically stable with no evidence of respiratory distress or serious infection. She did not require acute inpatient admission and could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: MDD, ADHD
Issue under review: Residential treatment

Determination:
The residential treatment was not medically necessary.

There is no information provided to support acceptable level of care guidelines for mental health residential treatment.  The programming as described in the documentation did not meet the intensity of treatment expected of a mental health residential treatment program.  There is no documented evidence that the patient had a psychiatric evaluation within 24 hours of admission.  There is no evidence that the patient met regularly with a psychiatrist over the course of his treatment.  There is no evidence that the patient required 24 hour daily observation and treatment.  Nothing in the documentation reviewed indicates that this patient could not have received equally effective psychiatric treatment at a less restrictive level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis, cerebral infarct, diabetes mellitus and congestive heart failure

Treatment: Alternate level of care in a skilled nursing facility

The insurer denied alternate level of care in a skilled nursing facility. That denial was reversed

This patient was admitted to an extended care facility for rehabilitation.  Currently under review is the medical necessity for continued alternate level of care in a Skilled Nursing Facility (SNF).

The clinical records demonstrated gradual functional progress that supported continued alternate level of care in a Skilled Nursing Facility (SNF).   For the time period under review, the patient demonstrated functional improvement for ambulation, dressing and transfer activities that ranged from minimal assistance to functional independence.  The additional approximately 2 weeks of therapy allowed the patient to meet discharge goals (for functional mobility and activities of daily living) with the ability to return home.   

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested coverage for the alternate level of care in a skilled nursing facility was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient substance detoxification treatment

The insurer denied the coverage for inpatient substance detoxification treatment. The denial was reversed.
This male patient was admitted to the inpatient substance detoxification treatment in the hospital on due to withdrawal symptoms including tremors, sweats, abdominal pain, diarrhea, anxiety, irritable mood, and elevated blood pressure. He had a Clinical Institute Withdrawal Assessment (CIWA) score of 15. He had past inpatient substance detoxification treatments. He also had diagnoses of Bipolar Disorder and Post-traumatic Stress Disorder (PTSD). He was put on a Librium protocol and left against medical advice.
The chart notes provided enough specific evidence to support that he required 24-hour inpatient detoxification treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This was the case with this patient, as he continued to drink large amounts of alcohol daily and use large amounts of Xanax, placing him at high risk for severe, complicated, and life-threatening withdrawal symptoms, including delirium tremens. He also was using cocaine daily. It was not likely that he could attend an outpatient substance detoxification treatment due to his continued use despite multiple past inpatient substance treatments; therefore, he required only inpatient substance detoxification treatment. He was also at risk for accidental overdose.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary. 

The timing of cholecystectomy in patients presenting with acute cholecystitis has been under intense investigation, with "early" cholecystectomy variably defined in the literature as gallbladder surgery performed within three, seven, or 10 days of symptom onset, and "delayed" cholecystectomy as that performed seven or 45 days, or six weeks, after initial diagnosis. Evidence from large database reviews and randomized trials generally associates cholecystectomy performed early during the initial hospitalization with better outcomes.

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

The patient should have no activity restriction unless the umbilical incision was particularly large. Then, limited heavy lifting for a few weeks is advisable. Most patients are able to return to work within one week. Patients follow up in clinic two to four weeks after their operation.

Most patients have some abdominal pain that resolves within two to three days after surgery and can be managed with analgesics. Occasionally, patients have referred shoulder and neck pain from the CO2 insufflation causing diaphragmatic irritation.

In this case, the patient was young, healthy, with no comorbid conditions. In addition, she was not septic, had a normal white count and had a routine surgery without untoward events. She recovered as expected, and she exhibited no signs or symptoms of any complications in the immediate postoperative period.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, hyperlipidemia, aortic regurgitation and peripheral vascular disease. He presented to the emergency department complaining of chest pain. His blood pressure was 155/96 millimeters of mercury (mmHg) with a heart rate of 75 beats/minute. His electrocardiogram showed left ventricular hypertrophy with repolarization changes. His chest x-ray was unremarkable. His serum troponin level was normal. The health plan's determination is upheld.
This patient, with multiple cardiac risk factors, presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS). Observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and a no acute electrocardiographic changes. There is no indication in the records provided that other potentially life-threatening diagnoses were considered likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital with a history of bipolar disorder and he presented with an unintentional overdose of olanzapine. The emergency department consulted the Poison Control center. The patient was admitted for an accidental overdose.  The health plan's determination of medical necessity is upheld in whole as an inpatient hospital admission was not medically necessary for this patient. The patient received supportive therapy with IV fluids and diagnostic testing with an EKG.  During the hospital stay, he was hemodynamically stable and did not have evidence of injury to other end organs. In addition, there were no other complications such as acidosis, sepsis, or prolonged encephalopathy.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for Diabetes and recurrent cellulitis. The patient presented with left lower extremity swelling. Per the patient, roughly 3 days prior on Thursday, he woke up in the middle of the night with pain in his left foot. The pain was accompanied by a small area of redness on his left foot. By Friday morning, the redness had expanded up to his left knee and the lower left leg had also become swollen. 

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient at hand had taken a total of 14 doses of oral antibiotics over a three-day period prior to evaluation in the emergency department and despite dual therapy with both doxycycline and clindamycin he had continued to have progression of symptoms. In addition once admitted the patient underwent additional imaging with CT after having an abnormal plain film. Given the presence of both findings and intervention indicators present to warrant an acute inpatient stay per InterQual criteria. This patient's hospital stay does indeed warrant admission to an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, suicidal ideation
Issue under review: Inpatient admission

Determination:
Inpatient admission was not medically necessary.

This patient consistently denied active suicidal ideation throughout her stay. While she continued to complain of depression and anxiety, she refrained from self-harm, active suicidality, or threats of suicidality. She admitted to passive suicidal ideation, but repeatedly denied plans or urges to act upon this ideation. She had a good rapport with staff, and she repeatedly agreed to inform them of any changes in her mental status. 

The documentation indicates that continued stay beyond the approved dates was due to long-term placement delays rather than due to clinical necessity between that date and discharge. The documentation does not support a clinical basis for continued acute inpatient care.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with a request for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol and stimulant (cocaine) class substances of abuse and had relapsed and begun to use alcohol and cocaine on a continuous daily basis with up to four pints of liquor and up to 1 gram of cocaine with intravenous (IV) administration, as well as use of crack cocaine with up to $200 worth use in a day.  The patient had prior substance use disorder treatments including at least 10 detoxification treatments and 1 rehabilitation treatment episode.  At the time of presentation, the patient was also requesting referral for rehabilitation substance use disorder treatment. 
The patient was admitted for inpatient treatment with a detoxification protocol and withdrawal management and supportive services, including care of his injury and fluid replacement and received tapering dosages of Librium and replacement of vitamins with the availability of comfort medications and as needed (prn) medications for pain, anxiety, and insomnia, including Depakote for mood stabilization.  The patient's hospital course progressed without incident.  Vital signs remained normal, and the patient reported tremor, anxiety, restlessness and insomnia with mild symptoms of withdrawal that diminished and resolved during the brief inpatient stay.  The patient was socially withdrawn with low energy, but participating in counseling and educational sessions, as well a 12-step peer-supported recovery groups.  The patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.  The health plan's determination is overturned.

The medically supervised inpatient detoxification and withdrawal management and other medical services could not have been safely or effectively provided at a lower level of care in this case.  The patient in this case was using large quantities of alcohol and cocaine on a daily continuous basis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring.  Detoxification and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.

Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, nausea, anxiety, irritability, restlessness and insomnia), which were being effectively addressed with Librium and supportive measures.  The patient had associated clinical features that included a mood disorder requiring maintenance treatment, the lack of sober supports together with limited insight, impaired judgment and poor control of impulses.
Appeal type: Medical necessity
Decision: Upheld

Diagnoses:  Gastritis

Treatment: Inpatient admission, diagnostic testing and medication management.

The insurer denied inpatient admission. That denial was upheld.

The patient developed sciatica and was taking non-steroidal anti-inflammatory drugs (NSAIDs) and steroids.  She presented with abdominal pain and melena.  She was afebrile and the vital signs were stable.  There was no abdominal rebound or guarding.  The hemoglobin was 10.7.  The patient was treated with Protonix.  An endoscopy revealed gastritis.  There was no indication of active bleeding or high risk endoscopic features.  She remained stable and was discharged on proton pump inhibitor (PPI) therapy.

Clinical indications for admission for upper gastrointestinal (GI) bleeding (M-180) include ongoing bleeding and high risk endoscopic features.  The patient did not have these conditions.  She also did not have hemodynamic instability, coagulopathy, syncope, or anemia with signs of cardiac ischemia. 

Clinical indications for admission for gastritis (M-560) include gastric outlet obstruction, perforation, peritoneal signs, severe dehydration, and ongoing bleeding despite observation care.  The patient did not meet these criteria.

This patient had been on NSAIDs and developed gastritis.  The NSAIDs needed to be stopped and the patient treated with PPI therapy.  This could have been done with observation status.  The endoscopy could have been done as an outpatient.  There were no high risk endoscopic features.  

The patient remained hemodynamically stable.  She did not meet MCG criteria for admission for either upper GI bleeding or gastritis.