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

Diagnosis: Bronchiolitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is a child with a history of 2 days of coughing and rhinorrhea. The mother was notified that the patient was breathing fast and having difficulty breathing at the day care center. The mother picked the child up at the day care center and when there was no improvement in the child's breathing she brought the child to the emergency room (ER) for treatment. The mother indicated that the child required albuterol treatments one year prior to the admission when the patient was sick with a virus.

In the ER the patient was noted to have nasal congestion, rhinorrhea and wheezing. On physical examination, the patient was noted to have intercostal and abdominal retractions. The patient was treated with albuterol and atrovent nebulizer treatments on three occasions. The patient was also treated with an intravenous (IV) bolus of normal saline and decadron. Blood testing indicated a low serum bicarbonate (HCO3) of 16 and an elevated c-reactive protein (CRP) and lactate level. When the patient's breathing did not improve, they were reexamined and noted to have grunting in addition to wheezing and the physician ordered 2 liters of oxygen supplementation to be started. Following treatment in the ER and the child was noted to have grunting, the decision was made to admit the patient to the hospital for continued treatment with albuterol every 3 hours with a diagnosis of bronchiolitis and a metabolic acidosis. 

The patient was treated appropriately in the ER for coughing, wheezing and increased work of breathing. The patient's increased work of breathing and wheezing did respond to treatment with 3 doses of DuoNeb, steroids and an IV bolus of normal saline. The child was noted to have continued wheezing and retractions following treatment and grunting was also appreciated indicating worsening status and risk of respiratory failure. The blood testing was abnormal supporting a metabolic acidosis with a low HCO3 of 16 and an elevated lactate level of 5.9. The child could not have been safely discharged since she required albuterol every 3 hours.

The child was not clinically stable after treatment and it was appropriate and consistent with the standard of care to admit the child with a diagnosis of bronchiolitis and a metabolic acidosis.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who had an inpatient hospital admission for 4 days. The patient presented to the facility's emergency department with the complaint of abdominal pain. The patient had no prior significant medical history. The vital signs were normal on presentation. A physical examination showed right lower quadrant abdominal tenderness on palpation. The patient's laboratory values showed a white blood cell count of 6.6. A computed tomography (CT) scan of the abdomen and pelvis showed possible mild appendicitis. The patient was then admitted for further evaluation. He received treatment with intravenous fluids, antibiotics, and supportive care. Repeat imaging did not show any evidence of appendicitis. The patient improved and remained hemodynamically stable throughout the entire hospital stay. The patient was then discharged.

The proposed treatment 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 an infection, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias, or any other indication for an acute admission. As such, the care could have been rendered at a lesser level. Therefore, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: coronary artery disease
Treatment: inpatient hospital
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who presented to the hospital for scheduled high risk percutaneous coronary intervention (PCI). His medical history was remarkable for hypertension, hyperlipidemia and type 2 diabetes. Cardiac catheterization performed prior had shown three vessel coronary artery disease. His left ventricular systolic function was normal. At that time, coronary artery bypass graft surgery was recommended but the patient declined and PCI was scheduled. Upon presentation, the patient had no acute complaints. 

Based on the documentation provided, the inpatient hospital admission was not medically necessary.
This patient underwent two vessel atherectomy and coronary artery stent implantation. Per the 2018 expert consensus document update from the society for cardiovascular angiography and interventions regarding length of stay following PCI, with the exception of patients with ST segment elevation myocardial infarction, inpatient admission is not generally required for stable patients after uncomplicated PCI. Same-day discharge is appropriate for the majority of patients. Per this document certain high risk procedures, including coronary atherectomy, justify overnight admission under observation status, but not inpatient admission.
The records provided document that this patient had a significant elevation in his high sensitivity troponin level post-procedure. This is common after PCI and, in the absence of new electrocardiographic changes, documentation of myocardial injury by imaging or procedural complications that result in significant reduction in coronary blood flow, troponin elevation alone is not diagnostic of PCI-related myocardial infarction. An inpatient admission was not warranted based on this man's elevated troponin levels.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia 
Treatment: inpatient stay 
The insurer denied the inpatient stay 
The health plan's determination is upheld. 

The patient is a male with a history of hepatitis C virus (HCV) / hepatocellular carcinoma (HCC), chronic kidney disease (CKD) stage 5, multi-organ transplant (liver, small intestine, pancreas), and type 2 diabetes mellitus (DM) who presented with abnormal labs with a hemoglobin of 6.7. 

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with a low hemoglobin of 6.7. He was asymptomatic without signs or symptoms of acute blood loss. He was hemodynamically stable. There was not respiratory distress. He did not have cardiac arrhythmias. He did not have evidence of end organ damage due to his anemia. He did not have documented hemolysis. He received 2 units of blood without any complications and was discharged home in stable condition. He was diagnosed with chronic anemia in the setting of CKD stage 5. The patient could have been safely and appropriately managed at a lower level of care with subsequent transition to outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg Pain
Treatment: Ambulatory surgery (procedure to improve blood flow in leg)
The insurer denied Ambulatory surgery (procedure to improve blood flow in leg).
The determination is overturned.

This is a male patient with multiple medical problems including congestive heart failure, diabetes, coronary artery disease, and hypertension, who was evaluated for right leg claudication. The patient complained of short distance right leg claudication after about a half block. He denied rest pain or skin breakdown.
The patient was noted to have an ankle brachial index (ABI) at 0.75 on the right and 0.83 on the left. He had a non-palpable right pedal pulse.
A computed tomography (CT) scan of the abdomen with runoff  demonstrated peripheral atherosclerosis including high-grade near occlusive stenosis of the distal right common iliac artery. The patient was diagnosed with peripheral vascular disease and intermittent claudication of the right leg.
The provider recommended treatment of his right leg with angiogram with possible angioplasty and stenting. At issue is whether the requested treatment is medically necessary.
The requested treatment of ambulatory surgery (procedure to improve blood flow in leg) is medically necessary for this patient.
The patient was diagnosed with peripheral arterial disease and claudication requiring treatment.
The recommended treatment, angiogram with possible angioplasty and stenting is medically necessary and is the standard of care for the treatment of peripheral arterial disease and claudication. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Radiation therapy

Diagnosis: breast cancer
Treatment: proton beam therapy
The insurer denied the proton beam therapy
The health plan's determination is overturned.

This is the case of a female patient with L (left) breast cancer who was treated with chemotherapy followed by lumpectomy for breast cancer. She is being planned for adjuvant RT (radiation therapy) to the breast and nodal basin using Proton beam therapy. 

The requested Proton Beam Radiation Therapy (PBRT) is medically necessary for this patient. The superior power of proton beam therapy may provide improvement in cardiac sparing especially in L (left) breast cancer.
This is young patient with curative disease with expected longevity and excellent performance status. We should try to avoid increased incidence of cardiac events using proton beam. The risk is linearly related to mean heart dose at a rate of 7.4% per Gy (gray unit) of mean heart dose. Proton beam therapy can keep the mean heart dose well below 5 Gy.
With photon beam therapy, this will result in significantly increased cardiac dose with the most sophisticated technology and treatment set up. The patient's tumor is located directly above her heart which requires significant planning to keep her mean heart dose below 5 GY.
Proton beam therapy is the only option to achieve full dose to the L breast and nodes and still stay within the Quantec dose threshold of heart less than 5 Gy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Back Pain.
Treatment:  Spinal fusion and decompression.

The health plan denied Spinal fusion and decompression.  The determination is overturned.

The patient is a male with low back pain for the past several years. He also has pain that radiates into his legs in an L (Lumbar) 5 distribution. Activity makes his symptoms worse. He has had symptom improvement with radiofrequency ablation (RFA) in the past. The patient reports a significant impact on his quality of life and activities of daily living (ADLs) as a result of his pain. His physical exam was notable for limited and painful lumbar range of motion.
A lumbar magnetic resonance imaging (MRI) scan demonstrated mild to moderate degenerative changes throughout the lumbar spine with moderate left foraminal stenosis at L3/4, L4/5, L5/S (sacral) 1. Lumbar x-rays show grade 1 retrolisthesis at L5/S1 with moderate disc height loss.
A computed tomography (CT) scan shows retrolisthesis at L5/S1 and disc space collapse at L5/S1 with moderate to severe neuroforaminal stenosis. Prior treatments include physical therapy (PT), non-steroidal anti-inflammatory drugs (NSAIDs), heat, muscle relaxants, and extensive injections. The patient was diagnosed with lumbar spondylosis, spondylolisthesis, and facet arthropathy at L5/S1 and an anterior/posterior fusion with decompression at that level was recommended.
At issue is the medical necessity of the spinal fusion.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of spinal fusion is medically necessary for this patient. The patient has chronic low back and bilateral leg pain with L5/S1 degenerative changes that correlate with his symptoms. He has tried exhaustive conservative management. He previously has gotten relief from RFAs at the L5/S1 level which would suggest symptomatic lumbar facet arthropathy and the standard of care treatment for that would be a lumbar fusion. The spinal fusion and decompression clinical policy is provided on page 169 of the packet. Using clinical scenario, the patient has nontraumatic grade I spondylolisthesis at L5/S1, back pain that interferes with his ADLs and no neurologic deficits on exam, and spondylolisthesis on imaging. He has tried the required conservative management and has continued pain. Therefore, the proposed surgery is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain status-post a laparoscopic left paratubal cystectomy
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient presented with abdominal pain and underwent a laparoscopic left paratubal cystectomy because of torsion. The procedure was uncomplicated and blood loss was minimal.

The patient presented with severe abdominal pain, and findings suggestive of torsion. The patient underwent an uncomplicated laparoscopy. A laparoscopy is an ambulatory procedure.
According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for: Older patients (> 65), conversion to abdominal procedures, surgical complications, comorbidities. This patient did not have any of these criteria. This procedure was uncomplicated. There was no evidence of any injury to other organs. The patient was tolerating oral intake and voiding adequately. The incisional pain was minimal.
 
Please note that a laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

The full hospital admission to is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Illness
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is upheld.

The patient is an adult female. She presented with four days of fever, chills, body aches, and sore throat. She had tested positive for COVID two weeks prior. The patient's vital signs were stable. Her temperature was 102.4. Her respiratory rate was 17, and oxygenation was 97% (percent). Her exam was remarkable for oropharyngeal erythema and exudate. Her neck computed tomography (CT) showed enlarged tonsils. Labs noted white blood cell count (WBC) 13.2, potassium 3.2, and creatinine 0.77. Electrocardiogram (EKG) showed sinus tachycardia. Chest X-ray showed no acute disease. The patient was admitted. Infectious Diseases was consulted. Plan of care included intravenous antibiotics and steroids. Clear liquid diet was ordered. She improved the next day and was cleared for discharge.

The Inpatient admission was not medically necessary. 

This patient was admitted with tonsillitis. The patient was febrile. Labs were remarkable for leukocytosis. Imaging was negative for abscess. She was able to tolerate oral intake. The MCG 
(Milliman Care Guidelines) Acute Viral Illness criteria are not met. The patient did not have pulmonary or systemic manifestations. She was hemodynamically stable. She did not have dehydration, inability to maintain oral hydration, acute renal failure, altered mental status, arrhythmia, tachypnea, respiratory muscle use, or airway obstruction. She did not require isolation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient has a history of COVID, asthma, schizophrenia, and gastroesophageal reflux disease (GERD).  The patient also has a cognitive impairment.  The patient presented to the hospital with complaints of shortness of breath and wheezing.  The patient also complained of some upper respiratory symptoms, including increased cough and chills.  

Vital signs on presentation were: blood pressure (BP) 134/87, heart rate 114, respiratory rate (RR) 20, temperature 97.5 degrees Fahrenheit (F), and oxygen saturation 97% (percent) on room air.  The patient was in no acute distress and was able to speak in full sentences.  A lung exam revealed wheezing bilaterally.  Heart sounds S1 and S2 were normal.  The patient was alert and oriented x (times) 3 (person, place and time).

The patient was admitted for an asthma exacerbation.  The patient was treated with intravenous (IV) steroids, magnesium, and bronchodilators via nebulizer.  The patient's white blood cell (WBC) count was 12.8, hemoglobin 13.4, electrolytes within normal limits, and venous blood gas (VBG) 7.35/46/32.  A chest x-ray (CXR) revealed no acute infiltrates.  The viral panel and respiratory syncytial virus panel were negative.  The patient had improved in the emergency department (ED).  Per the history and physical, the patient was in no acute distress.

The patient was continued on oral prednisone after admission.  Symbicort and Singulair were ordered and administered.  By the next day, the patient had improved.  The patient was afebrile and hemodynamically stable.  Oxygen support was titrated down.  The patient was in no acute distress, speaking in full sentences, and few rhonchi were heard on lung exam.  The patient's WBC (white blood cell) increased to 17, likely a result of steroid effect.  The patient was tolerating oral intake.  

This patient did not need acute hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. This patient remained stable after admission and was tolerating oral intake.  There was no evidence of pneumonia (PNA), pneumothorax, or pleural effusion on imaging. The patient was discharged home the next day.  The patient could have been discharged home after a period under observation with close follow-up in an outpatient setting.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Respiratory Infection. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient has a prior history of facial fracture and chronic ear pain with tinnitus. The patient presented to the emergency department (ED) with complaints of cough with some right sided jaw pain and ear ringing. The patient also complained of some mild chest pain while coughing. The patient usually uses some steroid drops for their ear symptoms but had run out of their meds. 

Vital signs on presentation were: temperature 98.4 degrees Fahrenheit, respiratory rate (RR) 16, pulse 74, blood pressure (BP) 134/76, oxygen saturation 95% on room air (RA). The patient was in no acute distress. The patient was speaking in full sentences. A head, eyes, ears, nose and throat exam revealed some chronic scarring of the right ear canal.  Lung sounds were clear bilaterally. Heart sounds in S1 and S2 were normal. The patient was alert and oriented times 3. The neurologic exam was non-focal. The patient's white blood cell count (WBC) was 12.2 and sodium (Na+) 128 (the patient has chronically low sodium).  A chest x-ray (CXR) showed no acute infiltrates. The respiratory viral panel was positive for rhinovirus. 

The patient was admitted for possible pneumonia (PNA). The patient was started on Azithromycin. The patient was also being ruled out for acute coronary syndrome (ACS).  An electrocardiogram (ECG) did not reveal any signs of ischemia. The patient's troponins were negative. 

The patient remained stable after admission. A myocardial infarction (MI) was ruled out.  There was no PNA on CXR. By the next morning, the patient had no more ear pain. The patient was afebrile and hemodynamically stable. The patient was subsequently discharged home on oral medications and ear drops. 

This patient did not need acute inpatient hospitalization for their viral syndrome. The patient was afebrile and hemodynamically stable, not hypoxic, and had no PNA on CXR.  The patient was tolerating oral intake. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. The patient's symptoms were consistent with a viral upper respiratory tract infection. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Developmental delay, congenital heart disease

Treatment: Caregiver Family advocacy and Support service (CFASS)

The insurer denied coverage for Caregiver Family advocacy and Support service (CFASS).

The denial is modified.
 

Given the age, trisomy, developmental delay, congenital heart disease, and patient dependent on feeding tube and with nursing coverage not entirely dependable; the Caregiver Family advocacy and Support service (CFASS) coverage needs to be further expanded from 8 hours /month to 16 hours per month (4 hours per week). This will ensure that patient will have the adequate resources for care in the community. The studies have shown that CFASS and related services have been successful in decreasing healthcare utilization.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The Caregiver Family advocacy and Support service (CFASS) coverage is medically necessary and needs to be further expanded from 8 hours /month to 16 hours per month (4 hours per week).