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

Diagnosis: Hypertensive Encephalopathy

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned. 

This is a patient female patient who was brought to the Emergency Room (ER) by emergency medical services (EMS) with bilateral hand and feet numbness, and a headache. She had a history of untreated hypertension. The patient's heart rate on presentation was 121 and her blood pressure was 213/152. The patient's Glascow coma scale was 15. The patient's speech was clear and there was no facial droop.  The patient moved all extremities with equal strength and had strong bilateral grips.  The patient followed all commands and denied dizziness, lightheadedness or change in vision. The patient's laboratory studies revealed creatine kinase 445, potassium 2.9, chloride 93, lactate 7.0, troponin 0.01, WBC 16.52, AST 54, ALT 57, and the urinalysis showed ketones 1+, blood 2+, and protein 1+.  The patient had sinus tachycardia on the cardiac monitor at 108.  There were no ST-T wave changes.  The patient's chest x-ray and computed tomography (CT) scan of the head showed no acute findings. Neurology was consulted.  The patient was treated with intravenous fluids, Ativan, and oral labetalol.  After the labetalol, the patient's blood pressures were in the 120s-130s/60s-90s range.  The patient ambulated to the bathroom with a steady gait. The patient moved all extremities and had positive sensation in all extremities.  The patient followed commands and denied any headache, dizziness, or changes in vision.  The patient was normotensive and had normal sinus rhythm on the cardiac monitor. The patient was admitted to Telemetry for the diagnosis of hypertensive encephalopathy, rule out seizure, and Norvasc was started.  The patient's urine toxicology screen was positive for cocaine and benzodiazepines.  The patient's electrocardiogram (EKG) was performed and was normal.  The patient's blood pressure was controlled and she was stabilized and discharged. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient developed headache, numbness and tingling with blood pressures elevated to 213/152 with a mean blood pressure of 172. The patient was diagnosed with a hypertensive emergency for which an inpatient admission is medically necessary. 

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

Based on the above, the medical necessity for the inpatient hospital services is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma Exacerbation.
Treatment:  Inpatient hospital services.

The insurer is denied coverage for inpatient hospital services.  The denial is upheld. 

This is a female patient with a history of hypertension, hyperlipidemia and asthma with the last attack documented over a year ago.  The patient presented to the Emergency Department (ED) with complaints of increasing shortness of breath for several weeks.  The patient denied fever or chest pain.  At presentation to the ED, the patient's vital signs were: temperature (T) 97.7 F, heart rate (HR) 70, respiratory rate (RR) 20, blood pressure (BP) 152/100 mm Hg and oxygen (O2) saturation 94% on room air (RA).  On exam, the patient was in no acute distress.  The patient's lung exam revealed bilateral wheezing, and her cardiac exam was within normal limits (WNL).  The patient's bloodwork showed:  white blood cell (WBC) count of 5.8K, hemoglobin of 3.9, and electrolytes were within normal limits.  The patient's chest x-ray showed no acute infiltrates.  The patient's electrocardiogram (EKG) showed no acute ischemic changes.  The patient's venous blood gas (VBG) showed pH of 7.38, pCO2 of 48, and pO2 of 62.  The patient was treated with nebulizers, oral prednisone, and magnesium supplementation.  The patient was admitted with diagnosis of asthma exacerbation.  The patient improved with treatment and remained stable after admission.  The patient was treated with oral medications, nebulizers and inhalers.  The patient was subsequently discharged. 

Based on the review of the medical record, inpatient hospital services were not medically necessary for this patient.  This patient did not have pneumonia or pneumothorax.  There was no evidence of hypoxia.  The patient improved with treatment in the Emergency Department (ED).  As per the History & Physical (H&P) note, the patient was in no acute distress and was speaking complete sentences.  The patient's Peak Expiratory Flow (PEF) was 200 after treatment.  The patient's vital signs were stable with temperature of 97.7, heart rate of 79, respiratory rate of 19, and blood pressure of 132/88 mm Hg.  The patient's oxygen saturation was 97% on room air.  The patient did not need acute hospitalization.  The patient could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient remained stable after admission . The patient was able to tolerate oral medications.  Thus, after a period of observation, the patient could have been safely discharged home on oral medications, tapering doses of steroids and close follow-up in an outpatient setting.

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

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

Diagnosis: Advancing dementia, coronary artery disease.
diabetes, incontinence.
Treatment: Increase in Personal Care Worker (PCW) service to seven days/week, 24 hours/day, continuous care by more than one person.
The insurer denied the Increase in Personal Care Worker (PCW) service to seven days/week, 24 hours/day, continuous care by more than one person.
The denial is overturned. 

The patient is a female who lives alone with diagnoses including advanced dementia, coronary artery disease, diabetes, hypertension, frequent incontinence of bowel and bladder, difficulty walking requiring a walker, abnormal gait even with a walker, and advanced osteoarthritis.  The patient requires extensive or maximum assist with most tasks of adult daily living.  Recently, the patient's dementia is documented by a family member and by her personal physician to be advancing.  The patient requires 24 hour a day seven days per week of medically necessary supervised skilled personal care worker.

Yes, the proposed increase in PCW service to seven day per week, 24 hours per day, continuous care by more than one person is medically necessary.

The patient requires extensive or maximum assist with most tasks of adult daily living.  

The health plan failed to consider the advancing level of dementia and its effect on the patient's ability to perform adult daily living task 24/7.  The patient demonstrates the necessary disabilities to support 24/7 personal care worker.  The disability documented in the medical records, documents and support documents as described above demonstrate a medically necessary need in order to meet the medical needs of patient.  Therefore, the increase in PCW service to seven day per week, 24 hours per day, continuous care by more than one person is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

This is a patient with a history of hypertension, obesity, hyperlipidemia and mitral valve repair.  Treatment of his hypertension with generic metoprolol 25 milligrams (mg) daily was ineffective.  His blood pressure has been well controlled with Toprol XL 50 mg daily (metoprolol succinate).  At issue is whether the formulary drugs (metoprolol, atenolol, bisoprolol, carvedilol, labetalol, propranolol, and Bystolic) will be or have been ineffective, would not be as effective as the non-formulary drug Toprol 50 mg tab ER 24H, or would have adverse effects.
The health plan's determination is upheld.
Per the information provided, generic metoprolol was previously ineffective in controlling this patient's blood pressure.  It is unclear if the patient tried generic metoprolol tartrate or generic metoprolol succinate.  Regardless, per prior authorization request, the dose tried was 25 mg, which is a very low dose.  In addition, in the absence of comorbidities for which a beta-blocker would be indicated, such as ischemic heart disease or heart failure with reduced ejection fraction, beta-blockers are no longer recommended as first-line agents for the treatment of hypertension.  Nonetheless, this patient has demonstrated a good response to beta-blocker therapy, and it would be reasonable to continue treatment with a beta-blocking agent.  The formulary alternative options mentioned above (atenolol, bisoprolol, carvedilol, labetalol, propranolol, Bystolic) would all be reasonable.  Metoprolol has not been shown to be superior to these agents as the anti-hypertensive effect of beta-adrenergic antagonists is a class effect and the different agents (with the exception of pindolol) result in similar blood pressure reduction whether used alone or in combination with a diuretic and angiotensin converting enzyme (ACE) inhibitor.  Current guidelines do not support the use of brand name metoprolol succinate over the formulary alternatives in this instance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Overturned in whole

This is the case of a patient who was brought to the emergency department (ED) due to difficulty breathing. There was no fever, but the patient had a runny nose for 3 days prior to presentation. He was seen at the pediatrician office and discharged home. The grandmother who helps care for the patient has recently been ill.
The ED vitals showed temperature (T) 98.3 Fahrenheit (F), heart rate (HR) 162, respiratory rate (RR) 68, and blood pressure (BP) 82/36, with oxygen (O2) saturation of 98% on room air. Physical exam was notable for rhinorrhea and mild tachypnea but otherwise normal. Influenza testing was positive for Influenza A; respiratory syncytial virus (RSV) was negative. This patient was started on Tamiflu and admitted to the hospital for monitoring. The patient remained stable and was able to be discharged home to complete a 5 day course of Tamiflu.

At issue is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole.

This patient was brought to the ED for concerns of congestion and difficulty breathing, was found to have mild tachypnea (RR 68) and Influenza A.

This is a patient who is high risk for complications due to influenza, due to prematurity and corrected age at presentation of newborn term gestation. The patient had tachypnea in the ED, noted both by RR of 68 (greater than [>] 60 is tachypnea for a newborn) and documented in the provider's physical exam. Although there was no fever present, tachypnea alone in a newborn can be a sign of sepsis. Thus, inpatient admission with close medical monitoring and initiation of medications was warranted for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female who presented to urgent care with right lower quadrant pain and was urged to go to the emergency department for evaluation. The patient's vital signs were unremarkable. The patient had a white blood cell count of 14.3 with a left shift. The patient had a computed tomography (CT) scan of her abdomen and pelvis which demonstrated acute appendicitis. The patient was hospitalized and underwent uncomplicated laparoscopic appendectomy. On postoperative day #1 the patient was doing well and was discharged home. Pathology demonstrated acute appendicitis. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

No, the inpatient stay was not medically necessary. The patient had acute suppurative appendicitis without perforation but did not have evidence of other complications. The patient did very well after surgery. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity for an inpatient stay. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain and back pain.
Treatment:  Inpatient admission.

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

The patient is a female who presented to the ED with complaints of abdominal and back pain.  She was evaluated, her vital signs were stable, and her exam was non-focal.  She was treated for a possible urinary tract infection and for constipation and was discharged to home.

No, the proposed inpatient admission is not medically necessary. 

The patient did not have unstable vital signs or laboratory evaluation or any medical condition that would have required acute level inpatient level of care.  She did not have any GI (gastrointestinal) condition or GU (genitourinary) condition that would justify inpatient level of care, such as pancreatitis, cholecystitis, renal failure or hydronephrosis.  The management of her constipation, pain and possible urinary tract infection could have been delivered at the observation level.  She did not have any conditions that required high intensity care or inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission.
The denial is overturned. 
The patient is a female who presented to the Emergency Department (ED) with right upper abdominal pain and vomiting. She reported that she had been to the ED the night before with the same complaints. An ultrasound was performed that was positive for multiple gallstones a normal gallbladder wall; there was no pericholecystic fluid. A physical examination was done that revealed right upper quadrant tenderness and positive bowel sounds. Surgery was consulted. There was a negative sonographic Murphy's sign. The patient was admitted to the hospital for intravenous (IV) fluids and antibiotics for the treatment of acute cholecystitis. The patient was stabilized and discharged.

The inpatient hospital admission was medically necessary for this patient. The patient presented to the Emergency Department for complaints of persistent right upper quadrant abdominal pain, nausea, and vomiting. Initial examination demonstrated right upper quadrant tenderness. Initial labs showed an elevated white blood cell count of 15.3. An ultrasound showed that the gallbladder was distended with multiple gallstones. The patient was admitted to the surgical service for management of acute cholecystitis.

Given the patient's symptoms, diagnostic findings, and planned surgery, the inpatient admission was medically necessary. The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ENT.
Treatment: Inpatient hospital stay.
The health plans determination is upheld in whole. The inpatient hospital stay was not medically necessary.

The patient has a right sided cholesteatoma and had a tympanomastoidectomy. There were no peri-operative complications as well as no operative complications. Patient  was admitted for intravenous (IV) antibiotics administration due to concern for complications like meningitis post operatively. The patient was discharged the following day. There is no documentation of intra-operative or peri-operative complications where IV antibiotics were needed. There was no documentation that patient had an active infection at the time of surgery.
IV antibiotics or any type of post-operative antibiotics have not been shown to be beneficial for ear surgery (see Patel). A Cochrane review concluded " There is no strong evidence that the large scale use of prophylactic antibiotics in clean and clean-contaminated ear surgery is helpful in reducing postoperative complications such as wound infection, discharge from the outer ear canal, labyrinthitis and graft failure." Additionally, meningitis is exceedingly rare in ear surgery. If there is no violation of the tegmen tympani and/or dura (as there was no violation per the operative report) the risk of meningitis is near zero.
In summary, there was no medically indicated reason for an inpatient admission for IV antibiotics based on the documentation provided. It is not considered standard of care to give IV antibiotics after a tympanomastoidectomy surgery. Therefore, medical necessity for an inpatient admission is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female. She has a history of a chronic neck wound for three years, diabetes, and anemia. She presented to the emergency room. She was seen earlier in the day at urgent care and was told to go to the ED due to elevated ESR/CRP (erythrocyte sedimentation rate/C-reactive protein) and the possibility of osteomyelitis. A previous culture showed staph aureus, and she was treated with Bactrim as an outpatient.

The patient was noted to have large ulceration from the left scapula to the neck. There was no erythema, fluctuance, or purulent discharge. She was afebrile at the time. WBC (white blood cell) count on admission was 6.6.  X-rays in the ED did not indicate osteomyelitis. 

The patient was treated with IV antibiotics. Wound culture was positive for MSSA (methicillin-sensitive Staphylococcus aureus).  Local wound care was provided. CT scan of the neck/chest was unremarkable. Her HgbA1c (glycated hemoglobin) was noted to be 14. Her hemoglobin was noted to be 8, and the patient declined a colonoscopy. Her hospital stay was unremarkable. 

Infectious disease recommended discontinuation of IV antibiotics, and the source of inflammation was unknown. Dermatology indicated wound was factitious dermatitis. The culture was determined to be due to colonization. 

On the day of discharge, the patient's wound measured 8 x 6 cm with no clinical signs of infection.  She was discharged on oral Cephalexin.

In this case, the patient did not have a fever, elevated WBC count, induration, pus or clinical signs of infection. If there were such findings in a high-risk patient, then admission would have been warranted (Ref 1). Chronic wounds are often colonized and can have bacteria on culture. The patient could have been treated at a lower level of care, such as Observation (ref 2). There was no need for surgery, acute interventions, or pain control. The dates of admission in question were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic fatigue
Treatment: Modafinil tablets
The proposed treatment with Modafinil is medically necessary.

The patient is a female who is being managed for her migraine and chronic fatigue with Modafinil.  She has no history of narcolepsy, shift work disorder, obstructive sleep apnea with excessive daytime sleepiness or multiple sclerosis associated with fatigue not responding to amantadine.

As there is no FDA approved treatment of fatigue, the requested services Modafinil and other central nervous system (CNS) stimulants are used as off-label indication for the management of fatigue.  These agents include:
1)	amphetamines
2)	dextroamphetamines
3)	Modafinil
4)	armodafinil
5)	Ritalin

As the patient has been on the requested medicine for a while, continuation of the requested services rather than changing to other CNS stimulants would be the standard medical practice.   Therefore, the requested Modafinil is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with Erythema Multiforme (EM) with oral ulcerations. The patient has been hospitalized for disease consistent with toxic epidermal necrolysis (TEN). The patient has used famciclovir, cyclosporine, Protopic, Otezla, topical steroids. The provider requests coverage for Enbrel 25 milligram (mg) injections every week. At issue is whether the Enbrel is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease
The health plan's determination is upheld.
Enbrel is not likely to be more beneficial than any standard treatment available for the patient's condition. Case series and case reports indicates that tumor necrosis factor (TNF) drugs may play a role in halting diseases such as TEN. However, there is a lack of clinical guidelines with regards to optimal dosing, frequency of injection, and duration of therapy. Additional studies are needed to further characterize the role of TNF-alpha () inhibition in the treatment of TEN. Therefore, the Enbrel is not likely to be more beneficial than standard treatment.