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

Mental Health
Mental Health: Inpatient

Diagnosis: schizoaffective disorder 
Treatment: Inpatient mental health
The insurer denied the inpatient mental health treatment. 
The health plan's determination is overturned in part. 5 additional days are medically necessary. 

The patient is a woman diagnosed with schizoaffective disorder, bipolar type (SCZBP). She also had a comorbid diagnosis of substance use disorder but details are not clear about the extent of her substance use or its relationship to her mental state in the emergency department. Case notes document that the patient suffers from chronic SCZBP. She was non adherent to her medications. She brought herself to the emergency department because of what her auditory hallucinations (AV) were telling her.

The Inpatient Mental Health Treatment (IMHT) for 5 additional days is medically necessary for several reasons. Her illness was severe and chronic. She was non adherent to taking her medications, meaning it would take some time to restore her to effective levels of medication. She was dilapidated with poor activities of daily living (ADL). She was at risk by not being able to care for herself. Case notes document that she was irritable and labile in her mood. While she showed some progress in being less paranoid, she had not reached a reasonable approximation of a baseline state. She had poor impulse control. Her speech was loud and pressured. She was uncooperative and irritable, angry and anxious. On day 3, she was less irritable, without agitation, but showing poor insight and judgment. She was not at a reasonable baseline state and was judged to be in continued need of IMHT. On day 4, she appears to have achieved maximum benefit and was at a baseline state. On that day, she had no deficits in impulse control. She had no suicidal or homicidal ideation. She was not experiencing any delusions or hallucinations. She was not agitated. She could therefore be discharged with good judgment, according to standards of best care, on day 5.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient stay

The denial is upheld. 

This was a female patient who presented to the Emergency Department (ED) with complaints of feeling weak and dizzy since the morning. The patient's symptoms worsened with movement and when she stood from supine position. The patient reported being on a new diet for several weeks and had been exercising more frequently. The patient also reported a recent history of heavy menses. The patient's physical exam revealed that the patient was obese and in mild distress. There were no other significant abnormalities on physical examination. The patient's laboratory studies did not reveal any significant abnormalities. The patient was noted to have runs of bigeminy while standing. The patient's electrocardiogram (EKG) was completed and revealed sinus tachycardia at 100 with unifocal premature ventricular contractions (PVCs). It was recommended that the patient be admitted to the telemetry unit for further management, as the patient was symptomatic with heart rate dropping from 62 to 40 upon standing and was associated with bigeminy. The patient was treated with intravenous (IV) fluids and her orthostasis improved after fluid administration. It was also recommended she utilize oral meclizine as needed. As per a neurology consult, the patient underwent carotid duplex, which had normal results.  The patient's echocardiogram revealed an ejection fraction of 55%. There were no further significant deficits during the hospitalization and after a period of stability, the patient was discharged to follow-up as outpatient.

Per the current reviewed literature, telemetry is defined as inpatient electrocardiographic monitoring not performed in an intensive or intermediate care unit.  Admission is indicated when there is one or more of the following: Suspected or proven acute ischemic cardiac event; Cardiac rhythm disorder or conduction abnormality; New administration or adjustment of treatment affecting cardiac rhythm or conduction; Following cardiac or major thoracic procedure; Cardiac disease; Drug overdose or poisoning; Uncorrected electrolyte abnormalities; or unexplained syncope or other neurologic event. 

In this case, the patient underwent a neurological consultation along with a cardiac evaluation during hospitalization with workup including a carotid Doppler study and an echocardiogram which were all normal. The patient's EKG showed sinus tachycardia.  The patient's diagnostic work up was unrevealing. Based on this patient's diagnostic workup in the ED, inpatient admission was not medically necessary. The patient could have been safely monitored at a less intensive level of care, such as observation status. 

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Total Knee Replacement

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was upheld.  

This is a female patient who was admitted to the hospital for elective left knee revision arthroplasty. Her past medical history was significant for hypertension, obesity (BMI 49.07), premature ventricular contractions (PVC) and obstructive sleep apnea. She underwent a revision arthroplasty left total knee with no post-surgical complications. She received pain medications and was able to ambulate with physical therapy (PT) services. She was discharged home with outside services in place. 

The pertinent facts were the patient underwent a revision knee arthroplasty. She had underlying medical conditions and BMI of 49.07. She required reconstructive knee surgery and complex wound closure with special VAC dressing. These findings were taken into consideration. Her post-surgical course was uncomplicated. 

There was no evidence of bleeding, infection or fever. The patient was able to tolerate oral medications and proceed with therapy. She had no problems with her wound. She did not require treatment for her underlying medical conditions. The insurer has allowed for overnight stay and the potential for inpatient admission should such complications occur. Although she was at increased risk, there were no medical problems to require the inpatient level of service. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is not considered medically necessary for this patient.

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

Diagnosis: Overhanging pannus

Treatment: Panniculectomy

The insurer has denied coverage for panniculectomy

The denial is overturned. 

This female has a history of sleeve gastrectomy. She who previously weighed 268 pounds. After the sleeve gastrectomy, her weight was 185 pounds.  She has a symptomatic overhanging pannus.  An office visit note states the patient reported irritation and rashes within the skin folds which have been refractory to topical treatments and panniculectomy was advised.

According to the American Society of Plastic Surgeons (ASPS) Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients", "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure.  For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive.  In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic.  Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature." 

The records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment with over-the-counter and prescription creams.  Photos show that she has a long heavy pannus that would be at high risk for moisture trapping and infections.  A panniculectomy will eliminate her rashes.  

The patient's condition meets both the InterQual guidelines for a panniculectomy and the Milliman Care Guidelines (MCG), 24th Edition for panniculectomy.

The patient has chronic maceration, recurrent skin infections, persistent rashes and an inability to maintain hygiene of the lower abdominal and genital areas.  She has been treated for months with over the counter and prescription topical medications. The records confirm problems with activities of daily living.  Photos show a long pannus that traps moisture.  Her weight is noted as stable for at least one year. 

Based on the ASPS, MCG, and InterQual guidelines, a panniculectomy is medically necessary for this patient. The health plan did not act reasonably with sound medical judgment.

The carrier's denial of coverage for a Panniculectomy is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin disorders /psoriasis
Treatment:Pharmacy/prescription drugs 
The insurer denied Humira 
The denial is upheld in whole

The patient with moderate to severe psoriasis vulgaris, which includes the groin and rectal region, and causes pain during urination and bowel movements, and interferes with performing daily routines. The patient has tried and failed topical fluocinonide, calcitriol (Vectical), Cutivate, and Fluticasone. No psoriatic arthritis was noted.
No, the requested Humira is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication, to standard, first-line systemic therapies such as either Methotrexate or Acitretin. Modern dermatology literature [1-4] supports the use of preferred medications as similarly efficacious to the requested Humira, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, consistent with modern dermatology literature [1-4] and as per current medical standards of care, Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-sided abdominal pain; pyelonephritis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female without past medical history who presented to the hospital with right-sided abdominal pain.  On presentation, the patient was afebrile with a blood pressure of 159/106 and pulse of 85.  The urinalysis was positive for white blood cells.  An abdominal ultrasound demonstrated no acute process.  Labs were notable for a creatinine 0.5, alanine aminotransferase (ALT) 105, aspartate aminotransferase (AST) 47, alkaline phosphatase 332, potassium 3.8, and white blood cell count 10.0.  Computed tomography of the abdomen/pelvis demonstrated acute pyelonephritis in the right kidney, splenomegaly, and mild hepatomegaly.  Intravenous fluids and intravenous antibiotics were provided.  The blood pressure normalized.  The urine culture grew gram-negative rods.  Antibiotics were transitioned to oral Bactrim.

No, the proposed inpatient admission was not medically necessary.

The patient had acute pyelonephritis but did not have bacteremia, failure of outpatient treatment, granulomatous pyelonephritis, pyelonephrosis, pyelitis, emphysematous pyelonephritis, urinary obstruction, hemodynamic instability, or renal abscess.  The white blood cell count remained normal.  The patient was not pregnant or immunocompromised.  There was no requirement for intravenous antibiotic therapy beyond an observation timeframe.  There was no evidence of intractable vomiting, altered mentation, or severe dehydration.  There was no evidence of multidrug-resistant organism.  Liver function tests were only modestly elevated and were not accompanied by evidence of acute hepatic failure.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of hypertrophic cardiomyopathy and paroxysmal atrial fibrillation. He presented to the emergency department complaining of palpitations. He also reported having had a few days of chills, cough and myalgias. He denied chest pain or dyspnea. His blood pressure was 115/86 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 98%. He was afebrile. His physical exam was unremarkable. Testing was positive for Influenza A. His serum troponin level was mildly elevated. He was treated with Tamiflu and intravenous digoxin and admitted to the hospital due to concern for acute coronary syndrome (ACS) based on the elevated troponin level. He was seen by a cardiologist who opined that there was no evidence of acute coronary syndrome (ACS). The patient was discharged. The medical necessity of an inpatient admission is at issue.

The inpatient stay was not medically necessary.
This patient was hemodynamically stable, there was no evidence of acute ischemia, he was not in decompensated heart failure, and was not at high risk for thromboembolism. For patients presenting with acute atrial fibrillation (AF), the safety a lower level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."
This patient's serum troponin level was mildly elevated. This is a common finding in patients presenting with supraventricular tachyarrhythmias, including atrial fibrillation, and is not necessarily indicative of coronary artery disease or acute coronary syndrome. In this case, per the cardiologist, there was no evidence of ACS and no treatment for ACS was instituted. Thus, the troponin elevation in this case did not warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Evaluation of elevated blood glucose 
Treatment: Inpatient admission 

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

The patient is a male. He presented with weight loss, polyuria and polydipsia. He was diagnosed with new onset type 1 diabetes. 

The patient's vitals were as follows: Temperature 97.3, heart rate 70, blood pressure 117/76. His labs were as follows: Glucose 374 mg/dL, pH 7.364, bicarbonate 25, beta-hydroxybutyrate 0.75, positive urine ketones. His A1C (glycated hemoglobin) was 11.5%. 

The patient was treated with intravenous fluids and magnesium and subcutaneous lispro insulin. His glucose improved to 147 mg/dL. He was seen by endocrinology. He was started on glargine insulin and lispro with meals and correctional scale. There was concern that the patient has not been compliant on initial conservative management for diabetes and that patient will be lost to follow up. 

No, the inpatient admission was not medically necessary. 

This patient presented with hyperglycemia and dehydration in the setting of newly diagnosed type 1 diabetes. He was hemodynamically stable. He did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. He had mild dehydration that responded to intravenous fluids. The documentation does not support that he failed management under a lower level of care. He was started on subcutaneous insulin, received diabetes education, and was discharged the following day. Therefore, no, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified Lack of Coordination, Attention Deficit Hyperactivity Disorder

Treatment: Thera Era OT, PT for dates of service

The insurer denied the Thera Era OT, PT for dates of service.

The denial was upheld.

This is a male child patient who has been diagnosed with unspecified lack of coordination, convergence insufficiency, attention deficit hyperactivity disorder, muscle weakness and unspecified amblyopia.  The patient's assessment indicated that the patient was unable to stick to four letters during the assessment.  The patient's eye-hand coordination involved the ability to manipulate small balls on a rocker board.  It was recommended to continue with therapy.  The patient continued with therapy and the patient was seen for additional treatment.  The patient was seeking proper input sequenced 3-step obstacle course and focused on proper before vision.  The patient was able to pull it together for vision; however, she required cueing.  The recommendation was made to continue with therapy.  The patient continued with therapy and documentation indicated that the patient was happy to attend therapy.  The patient's auditory assessment was bothered by music and the patient tolerated tactile stimulation to the face.

Based on the review of the medical record, there is indication that this patient has been receiving chronic therapy services.  Some therapy notes are provided for the time frame in question with no documented therapy evaluation with clear goals for therapy and an anticipated time to reach this patient's goals. There is also no documentation of any re-evaluation during this time frame to show evidence of significant and meaningful function gains being made that could not have been met without skilled services.  There is a lack of documentation of specific rationale as to why additional skilled therapy services would have been required.  Therefore, the therapy in question is not medically supported and is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for Thera Era OT, PT is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tenosynovitis.

Treatment: Acute inpatient admission

The insurer denied coverage for acute inpatient admission. The denial is upheld.

This patient is a female with a past medical history significant for an inguinal hernia. She presented to the Emergency Department with complaints of left hand pain and swelling. Vital signs on presentation included a temperature of 98.2F, a blood pressure of 149/89, a pulse of 100, a respiratory rate of 18, and an oxygen saturation of 99% on room air. Laboratory results included a white blood cell count of 8.2, hemoglobin of 10.4, a hematocrit of 32.7, glucose of 100, and a creatinine of 0.79.

The patient was started empirically on intravenous antibiotics (vancomycin and ceftriaxone). The clinical impression was flexor tenosynovitis of the left 4th digit. An x-ray of the left hand was normal. Surgery was consulted. The patient remained afebrile and hemodynamically and clinically stable. She was discharged to continue treatment (oral Augmentin) as an outpatient.      

According to the documentation, the patient presented with left ring finger tenosynovitis. Otherwise, she was afebrile and stable hemodynamically with no evidence for systemic toxicity. Laboratory values were unremarkable including a normal white blood cell count. Moreover, the patient did not require surgical intervention. Based on these findings, the patient did not fulfill criteria for an acute inpatient admission. The patient was stable for observation level of care. 

The prior determination of denial of acute inpatient admission has been upheld. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

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

Diagnosis: Gastroenteritis

Treatment: Hospital emergency admission 

The insurer denied coverage Hospital emergency admission. The denial is upheld. 

This patient was a transgender female with an immunocompromising condition that was stable with CD4 count over 200. The patient presented to the hospital with abdominal pain and diarrhea. She was afebrile and her vital signs were stable. There were no peritoneal signs. The patient was felt to have an infectious gastroenteritis. The hospital course of treatment and management includes Tylenol, Benadryl, Heparin injection, intravenous ceftriaxone, azithromycin, Bicillin injection, Omnipaque, Senokot, and magnesium oxide. The patient remained hemodynamically stable and her diarrhea resolved. She was then cleared for discharge to home. 

Clinical indications for admission for Gastroenteritis (M-170) include having a severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting, and severe dehydration. The patient did not have these clinical indications for inpatient admission.

The patient had gastroenteritis for which intravenous hydration and antiemetic could have been provided in the Emergency Room (ER) or as an outpatient. The patient could have been given an antibiotic as an outpatient. The patient remained hemodynamically stable and had normal renal function. The patient did not meet MCG clinical criteria for inpatient admission for gastroenteritis. The patient could have been managed with observation status. An inpatient admission was not medically necessary.

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

Based on the above, the medical necessity for hospital emergency admission is not substantiated.  The insurer's denial is upheld.