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

Diagnosis: Hypospadias

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is a toddler who was admitted for a hypospadias repair with tunica vaginalis flap, cystoscopy and revision of circumcision on the date of admission.  The patient was discharged on the day of surgery. The hospital is asking for an inpatient day.

The patient had an uneventful surgical procedure on the day of admission, an uneventful recovery and was discharged to home on the day of the procedure.      

Given postoperative stability, maintenance of normal vital signs, cardio-respiratory stability, the fact that the child was able to tolerate fluids and was discharged home from the recovery room, inpatient stay was not required.

"Hypospadias is one of the most common congenital anomalies in men. The condition is typically characterized by proximal displacement of the urethral opening, penile curvature, and a ventrally deficient hooded foreskin" (van der Horst, H. J., & de Wall, L. L. , 2017).

"Hypospadias is one of the most common urogenital anomalies in newborn males. It is defined as the combination of the displacement of the urethral opening on the ventral side of the penis, an abnormal ventral curvature of the penis, called "chordee," and an abnormal distribution of the foreskin with a "hood" present dorsally and deficient foreskin ventrally. Hypospadias can cause problems in voiding, and in adults, it can cause sexual problems and infertility" (Anand S, Lotfollahzadeh S., 2017).

"Hypospadias is the second most common congenital disorder in males after cryptorchidism, but it is the most common penile congenital malformation" (Donaire AE, Mendez MD., et al., 2023).                                                         

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces

The insurer denied braces. The determination is upheld.

The patient is a male with a Class II malocclusion, moderate maxillary crowding and severe mandibular crowding, severe overjet and severe overbite in a mixed dentition of 11 primary teeth remaining, severe transverse constriction of the maxilla, proclination of the maxillary incisors causing a lip incompetence. At issue is the medical necessity of braces.

Using the Handicapping Labio-Lingual Deviation (HLD) Index, cases need to have permanent dentition or be at least 13 years old to be eligible for a score. The patient still has 11 primary teeth and is under the required age, so an HLD score cannot be determined. Thus, the malocclusion in question does not meet the criteria for a handicapping classification, and treatment would not be considered medically necessary. Considering the presence of 11 primary teeth and age, according to the standard of care, the requested health service/braces treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Wegovy

The insurer denied coverage for Wegovy

The denial is overturned

The patient has obesity with a body mass index (BMI) over 40. The patient started Wegovy and weighed 313 pounds. There is a weight recording about six months later that showed the patient only lost 2.3% of their body weight. The insurance company has denied further coverage of the Wegovy since the patient did not lose 5% of their body weight. It is reported that the patient also has a thyroid condition which has affected their ability to lose weight. In addition, the Medical Exception Request Form states that there was a 6.4% weight loss. Subsequent to this, there was a shortage of Wegovy and the patient was off the medication for several weeks. It was at that time that the patient began to again put on weight.

Up To Date has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI of 30 or over or a BMI over 27 with related comorbidities. Semaglutide is a glucagon-like peptide-1 (GLP-1) agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits (1).

An article by Rubino et al. (2021) noted 803 participants in this study were randomized to either continue Semaglutide or to take a placebo after 20 weeks of Semaglutide treatment. Those who continued the treatment with Semaglutide had ongoing weight loss, a better lipid profile, improved glucose metabolism, better blood pressure control, and physical functioning scores. The group who took the placebo regained their weight. The article states that the result of this study emphasizes the chronicity of obesity and the need for treatments that can maintain and maximize weight loss (2).

This patient has obesity and has benefited from the Wegovy. The patient had a setback when they were unable to take the drug. The medical literature supports the continued use of Wegovy to treat obesity. The reported result of a 2.3% weight loss can be explained with not being able to take the medication and the patient's thyroid disease. 

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 Wegovy is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fish Bone Stuck in the Throat
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

According to the clinical records, the patient is an adult female. She presented with a fishbone stuck in her throat. The fishbone occurred the night before after eating dinner. In the emergency room, flexible laryngoscopy was performed to visualize the bone but then it became dislodged. A computed tomography (CT) scan showed a 13-millimeter object in the throat. The patient was admitted and then taken for direct laryngoscopy for removal of foreign body. She was provided with intravenous pain control and steroids during her recovery and discharged after being deemed stable. The request of this review is to determine if the admission was considered medically necessary.

The inpatient admission was medically necessary.

The patient needed to be admitted for pain control, steroids, and a surgical operation under general anesthesia. This was necessary in order to prevent an airway catastrophe from the foreign body. This is supported by the medical literature. According to a review (1), "Foreign bodies to the ear, nose, and throat often can be managed in the emergency department, particularly if the patient offers a history consistent with foreign body and is calm and compliant with the examination and removal attempts. Tips for success include analgesia, adequate visualization, immobilization of the patient's head, dexterity and experience level of the provider, and minimizing attempts at removal. It is critical to recognize the risks involved with certain retained objects (button batteries or sharp objects) and when to call a consultant to help facilitate safe, successful removal of objects to the ear, nose, and throat." According to a study (2), "The fish bone could be observed by the physical examination in the oral cavity and laryngopharynx in 198 patients (69.23 percent (%)). For those patients in whom the foreign body could not be observed in oral cavity and laryngopharynx, noncontrast computed tomography (CT) (from nasopharynx to diaphragm) was performed. The fish bone was discovered in the esophagus of 66 patients (23.08%). The esophageal fish bone was successfully removed by transnasal flexible esophagoscopy (TNE) in 55 patients, the fish bone moved to the stomach in 10 patients and one fish bone was removed by rigid esophagoscopy due to esophageal abscess. The esophageal fish bone was mostly found in patients aged 50 years and older."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive hepatopathy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has a history of hyperlipidemia and typical atrial flutter with prior ablation after which they were noted to have profound sinus bradycardia. The patient had been asymptomatic after the ablation but was diagnosed with congestive hepatopathy. The patient presented for dual chamber permanent pacemaker implantation in the setting of profound sinus bradycardia (25-40 beats per minute). Magnetic resonance imaging (MRI) suggested some right ventricular (RV) overload, improved since previous study. The patient underwent biventricular implantable cardioverter-defibrillator (ICD) implantation without complication. According to the procedure note the patient was to be observed on observation status overnight and discharged the following day. The order stated "admit to ambulatory overnight bed" [page 61 of the documentation].  The patient was observed uneventfully overnight. A chest x-ray the following day was without abnormalities and showed pacemaker leads in proper location.

The patient had an elective pacemaker ICD implantation. The provider order observation status for this patient which was appropriate. The patient was observed uneventfully overnight and discharged the next day, which was an appropriate use of observation status. A full admission was not medically necessary. 

As noted above a full admission was not medically necessary and observation status (which appears to have been ordered) was appropriate.

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 a full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

According to the documentation provided the patient presented with pain. As per the emergency department (ED) provider note the patient is an adult who complained of abdominal pain associated with fever, nausea, and vomiting. The patient had similar symptoms 1 year ago which spontaneously resolved.  The presentation was most consistent with acute appendicitis. According to the ED flowsheet the patient had a temperature of 102.8. Workup included labs and computed tomography (CT) of the abdomen. 

Surgery notes indicated the patient presents with right lower quadrant (RLQ) pain, associated with nausea, and vomiting. The patient was febrile to 103 with tenderness to palpation in the RLQ. White blood cell (WBC) count was 13. CT showed 14 millimeter (mm) appendix with fecalith. The plan was laparoscopic appendectomy.  The patient was started on Ceftriaxone and Flagyl, and made nothing by mouth (NPO).

The patient was taken to the operating room (OR) for laparoscopic appendectomy. Pathology revealed suppurative appendicitis with micro perforation.

The care could have been managed in a lower level of care (observation). There was no data that the condition did not get better or that the patient needed to stay in the hospital. A review of the records show that the patient could have been placed in observation under monitoring, had an evaluation, had testing and been treated symptomatically while awaiting test results. Consultation with other professionals could also be done in observation. There was no hemodynamic, pulmonary, neurological or metabolic reason for acute level of care. There was no positive test or other finding after evaluation by the doctors that would have required an acute level of care. The patient could have been kept in observation according to guidelines and with negative test results and improved symptoms been discharged form observation with an ambulatory plan of care.

The patient did not require an acute inpatient admission but rather observation status as they did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful. There was no evidence of a complicated post operative course requiring hospitalization and the patient was discharged within 23 hours (on the same day of surgery). Thus, the patient should have had the appendectomy performed under an observation status without acute inpatient admission. 

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: Upheld

Diagnosis: chest pain
treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who presented to the emergency department (ED) complaining of three days of intermittent non-exertional epigastric/chest pain. His medical history was remarkable for coronary artery disease, percutaneous coronary interventions, hypertension and hyperlipidemia. In the emergency department (ED), his blood pressure was 127 over 67 (127/67) with a heart rate of 66 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 99 percent (%). His electrocardiogram showed sinus rhythm without acute changes. His serum troponin level was normal and remained normal when re-measured. Chest X-ray showed no acute pathology. The patient was treated with famotidine, Maalox and acetaminophen. 

The inpatient hospital admission was not medically necessary.
This man, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. 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 of care. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain, Dyspnea, Nausea.
Treatment: Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

This is a female patient who presented to the emergency department (ED) complaining of intermittent chest pain, dyspnea and nausea. Her medical history was remarkable for hypertension, hyperlipidemia and obesity. Her electrocardiogram and serum troponin level were normal. A chest X-ray showed no acute pathology. The patient was treated with aspirin and was admitted to the hospital. Aspirin, a beta-blocker and a statin were prescribed. An echocardiogram was performed and showed normal left ventricular systolic function and no significant valve disease. The patient was discharged. The medical necessity for an inpatient admission under review.

Based on the documentation provided, an inpatient admission was not medically necessary.

This patient presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

Upon presentation, this patient was markedly hypertensive. There was no evidence of acute end organ damage. Based on the records provided, an inpatient level of care was not medically necessary for blood pressure management. There is no evidence that rapid lowering of blood pressure in patients with severe hypertension and no acute end-organ damage is of benefit and, in fact, it can be harmful. Outpatient titration of antihypertensive medications with lowering of blood pressure to goal over a period of weeks has been shown to be both safe and effective.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Otitis Media
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

The patient is a male who presented with severe otitis media 3 weeks after an adenotonsillectomy. He was well until 1.5 weeks prior when he developed right ear pain and a diffuse headache. He had had an adenotonsillectomy 3 weeks prior. On the day prior to presentation, he developed ear drainage and was started on Augmentin. He then began to complain of pain behind his right eye as well as continued headache and lightheadedness, so he was referred by the ear, nose, and throat (ENT) surgeon to the emergency department for suspected mastoiditis.
On physical examination in the emergency department, he was noted to have copious right ear drainage with swelling. There was concern for mastoiditis versus (vs) a post-operative complication. Laboratory values were obtained and were significant for an elevated white blood count of 18.1. A computed tomography (CT) scan showed right mastoid air cell opacification. He was subsequently admitted to the hospital for further care.
In the hospital, he was treated with intravenous vancomycin, ampicillin/sulbactam, and ciprofloxacin drops in the ear. He was also given Afrin drops and prednisone. He improved over time with treatment and his severe headache and eye pain had resolved and he was felt to be stable for discharge to home with follow up as an outpatient.
The inpatient stay is under review for medical necessity.

The requested health service/treatment of hospital admission was medically necessary for this patient. This is a patient who presented with severe otitis media and suspicion for mastoiditis. His symptoms were worsening despite appropriate treatment with antibiotics as an outpatient. He was being cared for by a specialist who recommended hospitalization for parenteral antibiotics. He had significant findings on examination and an elevated white blood count. He therefore required hospital admission for intravenous antibiotics, corticosteroids, specialist consultation, and close monitoring with additional treatment as needed. The decision making at the time of admission for this patient was consistent with his young age, the presence of a worsening infection despite appropriate treatment, and the need for therapies that could not have been delivered as an outpatient, including parenteral antibiotics and close monitoring for potential deterioration of clinical status. According to the Milliman Care Guidelines (MCG) Health General Recovery Care Guidelines, 26th edition, Head and Neck Disease; hospitalization is indicated for otitis media that requires treatment beyond the scope of observation care, as indicated by mastoiditis. This patient had purulent otitis media with suspected mastoiditis that was not responding to appropriate outpatient treatment. He therefore required hospital admission for treatment with parenteral antibiotics, specialist consultation, and careful monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: coronary heart disease, dementia other than Alzheimer's, age related cognitive decline, hypertension, hyperlipidemia, gastroesophageal reflux disease, functional urinary incontinence, atrial fibrillation, and chronic venous insufficiency. 
Treatment: Home Care/ Personal Care Level 2 Personal Care Services increase to 70 hours per week. 
The insurer denied coverage for Home Care/ Personal Care Level 2 Personal Care Services increase to 70 hours per week. 
The denial is upheld. 

This case pertains to an elderly female who lives alone. She has diagnoses of coronary heart disease, dementia other than Alzheimer's, age related cognitive decline, hypertension, hyperlipidemia, gastroesophageal reflux disease, functional urinary incontinence, atrial fibrillation, and chronic venous insufficiency. Medications include Advair, albuterol, amlodipine, baclofen, benzonatate, Breo Ellipta, Bystolic, dabigatran, diclofenac gel, docusate, fluticasone, gabapentin, hydrochlorothiazide, memantine, mometasone, ofloxacin, omeprazole, Oxistat, prednisolone, simvastatin, sucralfate, and triamcinolone. 

She is mildly cognitively impaired per a neurologist assessment. She is occasionally incontinent for bladder, and she is continent for bowels. There were no reported falls within 90 days of assessment. There were no reported hospitalizations within 90 days of assessment. She is totally dependent for meal preparation, housework, and shopping. She requires extensive assistance with toilet transfers, toileting, bathing, dressing lower body, and ambulation. She requires limited assistance with dressing the upper body and personal hygiene. She requires supervision while eating. She is independent with bed mobility. 

The tasking tool allotted time for assistance 5 days per week and noted 28.25 hours per week. Adding the extra two days brought the hours to 36.75 per week. The awarded 42 hours per week is sufficient for the assistance this patient needs with her activities of daily living. The hours can be split during the day to best accommodate her needs. 

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 Home Care/ Personal Care Level 2 Personal Care Services increase to 70 hours per week is not substantiated.