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

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Advanced Imaging. 
The insurer denied myocardial perfusion imaging. 
The denial is upheld.

The patient is a male with high blood pressure who described worsening dyspnea on exertion increasing from mild to moderate. An electrocardiogram (ECG) showed non-specific ST-T changes. The provider recommended myocardial perfusion scanning (MPI). The subject under review is the medical necessity for myocardial perfusion imaging.

The health plan's determination is upheld.

Myocardial perfusion imaging is not medically necessary for this patient based on the information provided. The patient had exercise-induced dyspnea. There was no evidence of evaluation of left ventricular (LV) function with echocardiography. The request is for myocardial perfusion imaging without first determining heart function. No mention of pulmonary issues was discussed. The provided information does not support the medical necessity for myocardial perfusion imaging.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Inpatient Hospital Stay
The insurer denied an Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN) and diabetes mellitus type 2 (DM2) who was admitted with complaints of (c/o) chest pain associated with dizziness and a headache. Her vital signs were unremarkable. Lab work was unremarkable. Imaging studies, magnetic resonance imaging (MRI) scan of the brain showed no acute pathology, computed tomography angiography (CTA) of the neck showed no acute pathology, a chest x-ray (CXR) showed mild interstitial opacities. An electrocardiogram (EKG) showed no acute ischemic changes. The patient was diagnosed with atypical chest pain and treated with , anti-emetics, beta-blockers, meclizine, Lexapro, benzodiazepines (BZDs), and aspirin. The patient underwent a diagnostic cerebral angiogram that showed a left posterior cerebral artery posterior (P)3 segment fusiform dilation with a maximum diameter of 2.1 millimeters (mm), no indication for treatment. Cardiology recommended an outpatient stress test. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o atypical chest pain. An EKG did not demonstrate any acute ischemic changes and cardiology did not recommend any acute interventions. For the chest pain, the patient's HEART [history, EKG, age, risk factors,and troponin] score was 4, indicating that the patient had a moderate score, and not a high score. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and negative cardiac biomarkers, no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at a lower level of care.
For the vertigo, the patient did not have any acute hearing loss, double vision, fixed neurologic deficits, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. The patient was treated symptomatically and responded well, with symptomatic improvement, to meclizine and anti-emetics, while receiving a thorough imaging and biochemical work-up. The cerebral angiogram showed an arterial dilation, but no treatment was indicated. Given the patient's clinical stability and provided interventions and clinical monitoring, these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Anemia and electrolyte disorder.
Treatment:  Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned in part.

The is a patient with a history of tobacco abuse, diabetes, angioedema, daily alcohol use, corneal ulcer transplant, hypertension, chronic kidney disease (CKD) stage V (5), and peripheral vascular disease (PVD) with fifth toe amputation. She had a calcium level of 6, hemoglobin (hgb) of 6.7, and creatinine of 3.52. Her baseline hgb was between 6-7. She was transfused 2 units of packed red blood cells (pRBC) and her Hgb went up to 8. Calcium and magnesium were replaced intravenously (IV). She was hydrated. 

Based on the records provided for review the inpatient days 1 and 2 were medically necessary to complete hydration and transfusion and to assess kidney function, Calcium and electrolytes after IV fluids. On the following day, oral replacement could have been done while closely following as an outpatient or observation level. Therefore, inpatient days 1 and 2 were medically necessary; however, inpatient days 3 to 4 are not medically necessary.

O'Neill W. C. (2016), "Hypocalcemia is common in advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD), and it is standard practice to correct this back to the normal range, presumably to prevent symptomatic hypocalcemia and help control hyperparathyroidism. However, there are few studies to support this approach, and recent data suggest that this promotes vascular calcification and adynamic bone disease. Whether setting a lower target will improve outcomes has not been tested, but existing data suggest that this may have minimal risks and substantial potential benefits and should be explored."

Schafer, A.L., and Shoback, D.M. (2016), "Treatment of hypocalcemia depends on severity and chronicity. A calcium infusion is indicated for severe acute and or symptomatic hypocalcemia, while the standard mainstays of oral therapy are calcium supplements and activated vitamin D metabolites."

Beyer, A., Rees, R., Palmer, C., Wessman, B. T., & Fuller, B. M. (2017), "One-hundred twenty-four (60.8%) patients were transfused packed red blood cells (PRBC) in the ED (emergency department). The mean pre-transfusion hemoglobin level was 8.5 g (grams) /dl (deciliter). There were 73 patients with a hemoglobin value 10 g/dl; 19 (26.0%) received a PRBC transfusion. A total of 54 (26.5%) patients were transfused platelets. The main indications were thrombocytopenia (27.8%) and neurologic injury (24.1%). Ten patients had a platelet level <10,000 (guideline recommended threshold for transfusion to prevent spontaneous hemorrhage). The mean platelet count for neurologic injury patients was 197,000 prior to transfusion. The primary outcome occurred in 26 control patients (12.7%), as compared with 28 cases (13.7%). 

The insurer's denial of coverage for the inpatient admission is modified. Allow inpatient days 1 and 2, but uphold denial of days 3 to 4 as not medically necessary. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary retention.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The health plan's determination is overturned.

The patient is a man presenting with urinary retention. He had several return visits to the emergency room (ER) for catheter related issues. He presented with clots, but no evidence of retention. His abdomen was benign and soft. Blood pressure (BP) was stable, pulse was 117, with elevated white blood cell count (WBC) 12,600. Concomitant medical issues included hypertension, coronary artery disease (CAD), tobacco use disorder, chronic obstructive pulmonary disease (COPD), and schizophrenia. He required bladder irrigation for clots. Antibiotics were given. He was taken to operating room (OR) for a transurethral prostatectomy. He was discharged on post operative day one (POD 1).

The inpatient hospital admission was medically necessary.

The present had repeated to the ER for clot retention and gross hematuria from the time of initial evaluation until his admission. The WBC indicated an infection. His treatment was proper and consistent with the standard of care.

The patient needed the inpatient hospital level of care to manage recurrent hematuria, clot retention, elevated WBC. and comorbidities to optimize the patient preoperatively.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Abdominal/Stomach Pain.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This is the case of a female, with a body mass index (BMI) of 50 who presented to the emergency room with abdominal pain, vomiting, and vaginal bleeding. She was found to have a Murphy's sign, cholelithiasis, and a leukocytosis. General surgery and obstetrics/gynecology were consulted. She was diagnosed with acute, uncomplicated cholecystitis and her vaginal bleeding was consistent with menstruation following childbirth. She was admitted and her pain improved. She declined surgery, as she was feeling better. The patient was then discharged to home.
At issue is the medical necessity for the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

No. This is not a medically necessary inpatient stay. This patient had mild cholecystitis without any evidence of cholangitis. She did not have any surgery. Her pain resolved within one day of admission. She was discharged on oral antibiotics. Acute uncomplicated cholecystitis is no longer considered medically necessary for an inpatient stay by InterQual standards. It is frequently treated in the outpatient setting now, even with operative intervention. There were no interventions that this patient had that would have required inpatient care.
In addition, fully outpatient management of cholecystitis, as well as at the observation level has been documented as safe and appropriate management. Even in situations where a cholecystectomy is performed, outpatient management of acute cholecystitis has been documented as safe. Oral antibiotics can be used to treat uncomplicated acute cholecystitis, thus an inpatient admission would not be needed for intravenous antibiotics, as was often done historically. [4]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral vascular accident (CVA).

Treatment: Inpatient rehabilitation admission.

The insurer denied coverage for an inpatient rehabilitation admission.

The denial is upheld. 

This is a man with hypertension, diabetes, cerebral vascular accident (CVA) with right hemiplegia.  He was status post a thrombectomy, tracheostomy, and a PEG (percutaneous endoscopic gastrostomy) tube insertion. He was readmitted to the hospital for respiratory distress and then returned to the rehabilitation Center. Under review is the medical necessity of continued inpatient rehabilitation. The patient was initially appropriate for inpatient rehabilitation. His ability to perform activities of daily living and functional mobility had the potential for significant improvement with intensive acute inpatient therapy. According to the occupational therapy note, the patient required moderate to maximal assistance for dressing and toileting. He required moderate assistance for bed mobility and transfers in physical therapy. He was only able to ambulate approximately 10 feet with a rolling walker and minimal assistance. However, more recent clinical notes were not available for review to support the medical necessity of continued inpatient rehabilitation.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient in this particular case. Considerations include the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.    

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, an inpatient rehabilitation admission, was not medically necessary.

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

The insurer's denial of coverage for an inpatient rehabilitation is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a previously healthy female who presented to emergency department (ED) with right lower abdominal pain of one-day duration. Her evaluation included physical exam, labs, and imaging. This yielded the diagnosis of acute appendicitis. The white blood cell (WBC) count at presentation was 6.1 thousand (K). She was treated with intravenous (IV) fluid and antibiotics. The patient underwent laparoscopic appendectomy. The operative dictation describes an uncomplicated appendectomy procedure. The anesthetic record indicates an uncomplicated appendectomy. Her post-surgical course was uncomplicated. She was monitored overnight and provided IV fluid, IV pain medications, and perioperative antibiotics. Vital signs remained normal throughout the hospitalization. She was afebrile with normal vital signs. She was tolerating a clear liquid diet. She was discharged.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The medical record does not support that inpatient level of care was medically necessary for this patient on these dates. The care and treatment provided could have reasonably and safely been provided at a lower level of care status. It is standard practice to perform uncomplicated appendectomy at a lower level of care status. This level of care would have also provided for initial assessment, provision of medication, appendectomy, and overnight monitoring. While laparoscopic appendectomy was medically necessary, an inpatient status was not required.
The records support that this patient presented with appendicitis. She underwent uncomplicated appendectomy. The early post-surgical course was uncomplicated. She had normal vital signs and was tolerating diet. She was discharged from the hospital.
There is no clinical documentation to support need for inpatient admission for this patient. The patient remained hemodynamically stable throughout the perioperative period and there was no documented complication of surgery. The records include no documentation of comorbid medical condition that required an inpatient level of care [such as conversion to open procedure, intolerance of diet, complications of procedure, thromboembolic disease, care for comorbidities, advanced age/decompensated physiologic status]. This patient's clinical needs could have been satisfied with a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: back pain
Treatment: Lumbar Epidural Steroid Injection
The insurer denied an Lumbar Epidural Steroid Injection. The health plan's determination is upheld.

The patient is a female. A letter of medical necessity states that the patient is currently being treated for chronic pain. The patient has had chiropractic care for the past 3 months with no relief. She has had a home exercise program and multiple episodes in the past with significant improvement. Epidurals were performed previously. The patient has had much improvement in the past. The patient is currently having an exacerbation.

Lumbar Epidural Steroid Injection is not medically necessary. The purpose of epidural steroid injections (ESIs), whether cervical, thoracic, lumbar, or caudal, is to achieve pain relief from nerve root irritation and/or compression and the resulting radicular pain related to encroachment by bone or disc herniation, restore range of motion, and facilitate progress with more active treatment modalities. Inflammation of the compressed nerve root is an important factor in the pathophysiology of radicular and discogenic pain. Radiculopathy must be documented and objective evidence on physical examination needs to be present. This is particularly true with a transforaminal ESI (Epidural Steroid Injection) since the steroid is deposited alongside the nerve root. Failure of conservative therapies is recommended prior to consideration of an interventional procedure such as an ESI.
In this case, the patient has had multiple prior injections, and such injections are not supported as sustained benefit is not noted. The MRI (magnetic resonance imaging) lumbar spine does not demonstrate neural impingement at the  L(lumbar)5 - S(sacral)1 level. Nerve impingement is generally required to proceed with an ESI as it correlates with better outcomes. Therefore, a repeat Lumbar Epidural Steroid Injection is not medically necessary for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Femoral artery stenosis.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.

The denial is upheld. 

This case involves a male who presented to the hospital complaining of pain after walking 1-2 blocks. He had a history of hypertension, hyperlipidemia, and benign prostatic hypertrophy and was subsequently admitted for a peripheral angiogram.  Records indicated that an arterial duplex revealed moderate to severe stenosis, and he was exhibiting Rutherford category 4 symptoms. A stent was placed in the right superficial femoral artery, after which the patient was monitored on telemetry. He was subsequently discharged once he was stable. The patient received a notice of adverse determination stating that the patient could have been placed in observation under monitoring and did not require inpatient admission. There were times that the patient had no hemodynamic, pulmonary, neurological, or metabolic reasons to be treated at an acute level of care. An appeal was submitted stating that admission was warranted based on Milliman Care Guidelines 25th edition using the guideline of ambulatory surgery exception criteria. 

The Milliman Care Guidelines indicate that for patients undergoing percutaneous revascularization of the lower extremity, the goal length of stay is ambulatory or one day postoperative. While the patient's past medical history, his age, as well as the procedure were taken into consideration, there were no significant findings within the clinical records to indicate that the patient could not have been rendered care on an observational level. The evidence did not demonstrate that there were any complications during the stent placement and the patient was stable following surgery. Therefore, after a review of the documentation and then reference to the Milliman Care Guidelines and current medical literature, the inpatient admission was not medically necessary.  

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: knee injury.
Treatment: Meniscectomy [Knee Surgery].
The insurer denied Meniscectomy [Knee Surgery]. 
The health plan's determination is upheld.

The patient is a female with a complaint of persistent right knee pain. The patient related this pain to a car accident in which the right knee sustained a direct impact. The patient failed conservative treatment and subsequently underwent right knee arthroscopic surgery for partial medial meniscectomy. 

The requested Meniscectomy [Knee Surgery] was not medically necessary for this patient.
The provided medical records in this case document that the patient underwent supervised physical therapy for persistent right knee pain. The office notes do not document that the patient complained of mechanical symptoms such as clicking or catching in her knee to suggest that she had mechanical symptoms from an obstructive meniscal tear in her right knee. In addition, the plain radiographs obtained by the orthopedic provider indicated medial compartment arthritis present in both of the patient's knees. Furthermore, there is no clear magnetic resonance imaging (MRI) documentation of any meniscal tearing in the right knee prior to surgery. Thus, the documentation in the provided records does not support the medical necessity of the right knee arthroscopic surgery performed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a female with history of HTN (hypertension) and DM (diabetes mellitus). She presented to the ER (emergency room) with worsening shortness of breath.

In the ER, the patient was found to have COVID-19 (Coronavirus 2019) pneumonia. The patient was started on IV (intravenous) remdesivir, IV steroids, IV antibiotics and supplemental oxygen. The patient was admitted to acute inpatient level of care for the management of COVID-19 pneumonia.

The health plan denied coverage of the inpatient admission as not medically necessary. This denial is being appealed.

Yes, the inpatient hospital admission was medically necessary.

The patient had COVID-19 pneumonia with oxygen desaturations. The patient was treated with IV remdesivir, IV steroids, IV antibiotics and supplemental oxygen. The remdesivir treatment is for 5 days for acute respiratory failure due to pneumonia. This is an IV medication that cannot be administered except acute inpatient level of care. Given the patient's signs and symptoms due to COVID-19 pneumonia, it would have been reasonable to expect prolonged hospitalization for the administration of IV medications to see significant improvement in this patient. The patient's treatment course would not have been expected to be safe and effective at a lower level of care. The treatment provided in this patient was reasonably expected to be provided that required an acute inpatient level of care.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.