Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a history of aortic valve replacement and recurrence of atrial fibrillation. He was taking anticoagulation previously. He underwent another ablation. He underwent an echocardiogram and his ejection fraction was found to be 20%. His left ventricle (LV) was dilated. The patient was fit with a LifeVest. 
The health plan's determination is upheld.
This patient developed cardiomyopathy. The standard work up was negative for coronary artery disease. His cardiologist suspected that his recurrent atrial fibrillation with rapid ventricular rate was an underlying cause for his cardiomyopathy - so called "tachycardia induced cardiomyopathy". His provider recommended to treat this patient and to reassess his left ventricular function in 6 months. If his EF did not improve in 6 months, he would be a candidate for implantable cardioverter defibrillator (ICD) implantation for primary prevention. The patient was wearing a LifeVest in the interim.
This patient has a low left ventricular ejection fraction, less than 35%, therefore, he is at risk for sudden cardiac death. Current American College of Cardiology (ACC) / American Heart Association (AHA) guidelines recommend implantable cardioverter defibrillator (ICD) implantation not earlier than 90 days after diagnosis of dilated non ischemic cardiomyopathy was established and guidelines directed medical therapy was started. Medical therapy is to be started at the time of diagnosis. 
Because of the waiting period from diagnosis to ICD implantation, some cardiologists use a LifeVest in the interim, to "protect the patient" for sudden cardiac death. However, the benefit of this protection (with WCD) is still the subject of research. No definitive data are available on comparative efficacy versus alternative (or no) treatment
Based on the most recent advisory , a wearable cardioverter defibrillator (WCD) for this patient has class IIb indications, which means, not generally recommended: A service classified as a IIb indications with level of evidence C, should not be considered standard of care. Application of a LifeVest might appear to protect the patient from sudden death and gives comfort to provider, however, it lacks any evidence of survival benefit and, on multiple trials, failed to demonstrated clinically and statistically significant outcome.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a history of hypertension, atrial fibrillation. He has a prosthetic heart valve with an ejection fraction (EF) 20%. He had recurrent atrial fibrillation and was scheduled for ablation at which time he was noted to have an EF of 20% and heart failure. A request for a LifeVest was made.
The health plan's determination is upheld.
The proposed use of a wearable cardioverter defibrillator is not likely to be more beneficial than the standard treatment in this patient.  The patient had an EF recorded in the documentation of 20% during an episode of recurrent atrial fibrillation prior to the scheduling of an ablation. The patient had prior atrial fibrillation (afib) and subsequently went into sinus rhythm. The recurrent episode of atrial fibrillation was associated with heart failure. The atrial fibrillation is to be corrected with ablation at which time a follow up would be obtained. There is no evidence that this is a high-risk patient with a dilated cardiomyopathy associated with atrial fibrillation. There is no documentation of confirmed coronary disease, ongoing ischemia or prior infarct, significant arrhythmias or prior episodes of the sudden cardiac event nor progressive declining heart failure.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a history of aortic valve replacement , permanent  placement, and atrial fibrillation, status/post (s/p) ablation in. He also has a history of re-do aortic valve replacement. Following this surgery, he had recurrent atrial fibrillation, and underwent repeat ablation.  He was diagnosed with systolic heart failure, and found to have an ejection fraction (EF) of 20%. He was felt to possibly have a tachycardia-induced cardiomyopathy. A LifeVest was prescribed.
The health plan's determination is upheld. The wearable defibrillator is not proven to be more beneficial than any standard treatment or treatments for the patent's condition. There are no randomized, controlled trials of patients with newly diagnosed dilated cardiomyopathy showing improved outcome compared with standard medical care. The current American College of Cardiology (ACC) science advisory does not recommend the wearable defibrillator for this subgroup of patients. It is a class II B indication, meaning that there is some divergence of opinion, but at this time, the weight of evidence is against use of the wearable defibrillator for newly diagnosed nonischemic cardiomyopathy.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who had presented to the emergency department for evaluation of chest pain, palpitations, and left arm numbness. He was hemodynamically stable and there was no hypoxia. Physical examination was unremarkable. Review of laboratory data was significant for mild normocytic anemia and normal troponin. There were no ischemic electrocardiogram (EKG) changes and chest x-ray was negative for acute cardiopulmonary process.

He was admitted for management of chest pain. Serial troponin ruled out acute coronary syndrome. Echocardiogram revealed normal left ventricular systolic function and was negative for wall motion abnormalities or hemodynamically significant valvular disease. Cardiology consultation made an assessment of atypical chest pain. Statin therapy and outpatient follow up were recommended. The patient was discharged.

The health plan's determination is upheld.

No, documentation does not support medical necessity for inpatient level of care. The patient could have been adequately managed at a lower level of care. The patient presented with chest pain and palpitations. there was no hemodynamic instability or hypoxia. Acute coronary syndrome was ruled out. There was no clinical evidence of other life-threatening etiologies of chest pain such pulmonary embolism, thoracic aortic dissection, or tension pneumothorax. There was also no documentation of arrhythmia on cardiac monitoring and echocardiogram was negative for structural heart disease.
Appeal type: Medical necessity
Decision: Upheld

This is the case of a patient with a past medical history significant for hypertension, hyperlipidemia, and a recent diagnosis of Bell's palsy, who presented to the emergency department with a chief complaint of chest pain associated with sweating and palpitations. The patient rated the chest pain as 8/10 and non-radiating. He also endorsed upper abdominal pain. His history was significant for the patient having become upset after he received the news that his daughter had run away and for having had reported syncope without associated head trauma.

On presentation to the emergency department, the patient was noted to be afebrile, mildly hypertensive, with heart rate (HR) 92-100, and with oxygen saturations >90% on room air. His exam was otherwise noted to be within normal limits. A complete blood count (CBC) was notable for white blood cell count (WBC) of 14.3 and hemoglobin (Hgb) of 17.1. A comprehensive metabolic panel (CMP) and troponin were noted to be within normal limits aside from a mildly elevated bilirubin. An electrocardiogram (EKG) was not suggestive of acute ischemia or arrhythmia. A chest x-ray (CXR) showed evidence of atelectasis. Given concerns for chest pain and an episode of syncope, the patient was subsequently admitted to the hospital. 

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. This gentleman presented with what was felt per the admission history and physical (H&P) to be atypical chest pain and an episode of syncope in the setting of having received stressful news about his daughter. Serial troponins and an EKG were not suggestive of acute ischemia. He did not have recurrent syncope. He did not have hemodynamic instability, cardiac arrhythmia, or other reason for chest pain such as pulmonary embolism or dissection. In the absence of cardiac ischemia, cardiac arrhythmia, recurrent syncope, or other reason for requiring care at the acute inpatient level of care, acute inpatient admission was not medically necessary. His treatment could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting and Nausea
Treatment:  Inpatient admission
The proposed inpatient admission was not medically necessary. 

The patient presented with a common postoperative condition secondary to her particular operation.  Patients with a longstanding hiatal hernia often have delayed gastric emptying after the repair, mediated by possible mechanisms of an atrophic gastric musculature or vagal neuropraxia from the dissection.  If the barium swallow study shows an adequate repair, patients are started on a clear liquid diet and advanced to soft solids as tolerated.

Patients are typically discharged on the first or second postoperative day after a laparoscopic or robotic repair.  Patients are instructed to follow a low residue diet for two to three weeks following discharge from the hospital.

This patient did not show any signs and symptoms of bowel compromise, sepsis, or infection.  Diagnostic workup with labs and imaging confirmed a non-surgical problem and she responded to appropriate medical therapy. 

There were no surgical signs and symptoms of infection, sepsis, or bowel obstruction.  Appropriate workup was performed, and this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, emesis and nausea
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The care as provided to the patient was medically appropriate but the level at which the care was rendered was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had a possible acute pancreatitis episode; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  There were no radiology findings consistent with acute pancreatitis. As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who presented with difficulty breathing, barky cough, and clear rhinorrhea for 3 days.  She also had subjective fever 1 day prior to presentation.  She was given Decadron intramuscular (IM) 6 milligrams (mg) and one racemic epinephrine.  She was afebrile to 99.2, not tachycardic, heart rate (HR) 116, or tachypneic, respiratory rate (RR) 30 and oxygen (O2) sat 99% on room air (RA).  She did not have any respiratory distress or stridor. Flu and respiratory syncytial virus (RSV) were negative. She was admitted for respiratory and stridor monitoring.  Progress notes from the ER document that the patient remained comfortable with no inspiratory stridor, but the patient's mother did not feel comfortable going home given patient needing Decadron x 2 and racemic epinephrine in the past 2 days.  Admission exam documents RR 22, with clear breath sounds bilaterally, no wheezing, crackles, retractions or stridor.  On the floor x-ray of the soft tissue of the neck shows subglottic airway with symmetric narrowing.  Findings were suggestive of croup.  She did not have any stridor at rest or respiratory distress and continued to remain stable.  The patient received no Decadron or racemic epinephrine in 24 hours, no stridor at rest or with agitation.  She was discharged home with primary medical doctor (PMD) follow up in 2 days.

The health plan's determination is upheld.

The requested health treatment of inpatient stay was not medically necessary for this patient.  This patient presented with history of barky cough and difficulty breathing.  This visit was her second to the ER in less than 24 hours.  She received IM Decadron as well as racemic epinephrine.  Her symptoms resolved with ER management.  After admission she did not have any further respiratory distress or stridor.  She did not have any oxygen requirement.  She did not have any PO intolerance or signs of dehydration documented on exam.  After admission this patient had no further symptoms and did not require any highly skilled or technical care to manage her condition.

Studies have shown it is "safe to dismiss a child who has received nebulized epinephrine for croup from the emergency department after 3 to 4 hours of observation if the child has:

- No stridor at rest
- Normal air entry
- Normal color
- Normal level of consciousness
- Received one dose of 0.6 milligrams per kilogram (mg/kg) dexamethasone orally or intramuscularly"

This patient met all criteria for discharge from the emergency room post racemic epinephrine administration.  All of her respiratory assessments after admission were stable with no distress or return of stridor.  For these reasons inpatient stay was not medically necessary.  The patient could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Adnexal Cyst, Rib Fracture 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a female patient who was transferred from another facility for management of a large pelvic mass. She has history of Crohn's Disease, migraines, a blood clot in the neck, and thyroid disease. The patient was admitted to the hospital and the plan was to operate on the pelvic mass during that admission. The patient had a CT scan which revealed a posterior rib fracture. She has a chest x-ray which revealed no evidence of a pneumothorax.  Trauma surgery was consulted and it was decided to postpone the surgery for two weeks allowing the rib fracture had improved. The patient's pain was controlled and she was then discharged home.

This patient was admitted for surgical removal of a pelvic mass. The patient was stable and afebrile. There was no evidence of ovarian torsion or cyst rupture. The patient's pain could have been easily controlled as an outpatient until properly scheduled for surgery.

A Gynecology consultation does not require admission. Surgery for a pelvic mass for a healthy young female does not require pre-operative inpatient management. A fractured rib with no evidence of pneumothorax also does not require inpatient management.

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

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm Contractions

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.          

This is a young female patient who was 34 weeks and 6 days of gestation who presented with complaints of painful contractions and intermittent chest pain in early 2019. Her contractions were 5-7 minutes apart and cervical effacement was 50%. Dilation progressed from two centimeters to three centimeters. The fetus was at a -1 station. The patient was admitted with preterm contractions. She had a history of molar pregnancy, gestational hypertension, multiple spontaneous abortions, two dilation and curettages, traumatic brain injury resulting in blindness, migraines, asthma, and tetrahydrocannabinol use. Her membranes were intact, she denied leakage of fluid or vaginal bleeding, and the fetal heart rate was reassuring. The non-stress test was reactive and positive for fetal movement. The patient received intravenous (IV) fluid and 2 doses of steroids for lung maturation. The patient was discharged after a period of medical stability.

MCG guidelines list the following clinical indication for antepartum admission:
* Condition requiring premature delivery
* Delivery
* Fetal distress or demise
* Preterm labor and positive fFN
* Significant maternal disease, infection or comorbidity as cause
* Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa Or placenta accrete
* Continued fetal monitoring
* Tocolytric therapy that requires inpatient care
* Complications of tocolytic treatment

This patient was stable and did not have any of the above.  The management that this patient received could have been easily done in a less acute setting. Once the provider ascertained that there was no evidence of active labor, the patient could have been sent home. This is in accordance with standard of care and Milliman Care Guidelines.

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancolitis  
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a young adolescent male who presented to the hospital with vomiting and bloody diarrhea for two weeks. He has a history of celiac disease.  
The patient had an upper gastrointestinal endoscopy which resulted normal. The colonoscopy revealed pancolitis. The patient was treated with intravenous fluids, intravenous Solu-Medrol, and prednisone. Labs were trended and medications were given as ordered during the hospitalization. The patient was discharged after his symptoms improved.
Clinical indications for admission for Inflammatory Bowel Disease (M-565) include having acute severe ulcerative colitis as manifested by systemic illness.  In this case, the patient was not tachycardic or running high fevers.  The C-reactive protein was normal.  In addition, the patient should have severe symptoms which were not responsive to outpatient therapy.  In this case, there was no trial of oral steroids as an outpatient.  The patient also did not have an abdominal abscess, toxic megacolon, perforation, vomiting that was unresponsive to treatment, acute renal failure, or altered mental status.

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia nervosa
  
Treatment: Residential treatment for an eating disorder

The insurer denied the Residential treatment for an eating disorder. The denial was reversed.

This is a female patient who was admitted for inpatient residential treatment for eating disorder symptoms because she had weight loss with a weight of 101.3 lbs. Her ideal body weight (IBW) was 127, so she was 80% of her IBW.  She also had restricting eating behavior, decreased caloric intake, excessive exercising, and medical issues; including bradycardia, hypotension, presyncope, amenorrhea, low body weight, severe mitral regurgitation, poor response to past outpatient treatment, and she had a major recent and rapid weight disruption.  She had a heart rate of 37 initially. She had a diagnosis of anorexia nervosa.  She also had co-morbidities of anxiety and depression, and past alcohol and benzodiazepine use. She took Zyprexa and Trazodone.  She left against medical advice (AMA) and did not attend the recommended Partial Hospital Program (PHP) due to financial concerns, missing her family, and a desire to get back to work. She was discharged.

The insurer denied coverage for inpatient residential treatment for eating disorder as not medically necessary; stating that she did not require 24-hour treatment and could have been treated in a less restrictive level of care.

The chart notes provided enough specific evidence to support the patient required 24-hour residential treatment.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders indicates the least restrictive level of care for safe and effective treatment is appropriate.  It also reports that patients with weights of less than 85% of ideal body weight, severe co-morbid psychiatric symptoms, poor to fair motivation, preoccupation with intrusive, repetitive thoughts about eating for 4-6 hours per day, or necessity for supervision of all meals to avoid restricting behaviors, are candidates for residential treatment. The APA guidelines indicate patients that need supervision at all meals are in need of 24-hour residential treatment.  Anorexia nervosa is a chronic and difficult disorder to treat, so she required more than outpatient treatment during this time to treat her symptoms, as eating disorder symptoms worsened in terms of weight loss, and medical consequences. 

As a result, inpatient residential treatment for eating disorder was medically necessary. The health care plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  

The carrier's denial of coverage for residential treatment for an eating disorder is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; vomiting
Treatment: Inpatient admission

The proposed acute level inpatient admission was not appropriate or medically necessary.

The patient is a female who was admitted with chief complaints of abdominal pain, nausea and vomiting. She presented to the emergency department (ED) with one-day history of right-sided flank pain and bloody vomitus. She initially started with five to six episodes of non-bloody, nonbilious vomiting and then noticed blood in the vomitus a day before her visit to the ED. The patient gave history of dysphagia and abdominal pain for many years. The symptoms became more discomforting in 2017, and became more severe one week prior to her visit to the ED. She also complained of dysphagia with food (both solids and liquids) getting stuck for the past one year.

In the ED, the patient was hemodynamically stable and afebrile. Her complete blood count (CBC) and comprehensive metabolic panel (CMP) were essentially unremarkable. She was started on intravenous (IV) fluids and IV Protonix 40 milligrams (mg) twice daily (BID). The Gastroenterologist (GI) was consulted for further management of the patient's symptoms of abdominal pain, nausea and vomiting, and dysphagia. The patient underwent esophagogastroduodenoscopy (EGD) which revealed mild gastritis and large amount of food in the stomach consistent with gastroparesis. The biopsies were done from the esophagus to rule out eosinophilic esophagitis and gastric biopsies were done to rule out Helicobacter (H) pylori gastritis.  The patient was discharged home on Protonix 40mg by mouth (PO) daily and Reglan suspension 10mg PO three times daily (TID) for 14 days, and was advised to take small, frequent meals.

 
The patient presented with abdominal pain, nausea and vomiting which was initially non-bilious and non-bloody and then became bloody a day before the procedure. She was hemodynamically stable in the ED, and her CBC revealed normal hemoglobin (Hb) / hematocrit (HCT) and normal white blood cell (WBC) count, and CMP revealed normal electrolyte, blood urea nitrogen (BUN) / creatinine, and normal liver function tests. The patient was evaluated by the Gastroenterologist and on EGD had no evidence of active bleeding lesions such as peptic ulcer, erosive gastritis, or Mallory-Weiss tear. The EGD showed a large amount of food consistent with gastroparesis. The patient was discharged home on Protonix and Reglan, and advised to take small meals. Given this clinical scenario, she could have been safely managed under lower level of care, and acute level inpatient was not required.