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

Diagnosis: Respiratory system/breathing problem.
Treatment: Inpatient hospital.
The insurer denied the entire inpatient stay.
The denial is overturned in whole.

This is a patient, at the time of admission, who presented with a choking episode. The patient  was sleeping in her bassinet on her back and she woke up from a nap mother went to go mix her bottle and heard choking/gagging sounds. 

Yes, the requested health service/treatment of inpatient hospital admission is medically necessary for this patient.

This patient presented with an event that was described as  "foaming at the mouth" with head and back arched and then hypotonia. The episode lasted for approximately 2 minutes. Given the patient's age of < 60 days as well as duration of event > 1 minute, this child would not be considered a low risk patient after such an event and would require admission for cardiopulmonary monitoring.

The American Academy of Pediatrics, in May 2016, released low risk criteria for patients that can be conservatively managed following a brief resolved unexplained event (BRUE). Low risk patients include age >60 days, gestational age >=32 weeks and postconceptional age >=45 weeks, occurrence of only 1 BRUE (no prior BRUE ever and not occurring in clusters), duration of BRUE < 1 minute, no cardiopulmonary resuscitation by trained medical provider required, no concerning historical features and no concerning physical examination findings. This patient did not meet these criteria and inpatient admission for close monitoring and possible further workup would be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain.
treatment: inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient has a past medical history of hypertension and hyperlipidemia. He presented with chest pain, nausea and vomiting, diaphoresis, and a syncopal episode. The initial blood pressure (BP) was 60/40. In the emergency department (ED), he was administered intravenous (IV) fluids. The BP increased to 102/60 and other vital signs were normal. He had been having the chest pain four years. Troponins were negative. A computed tomography (CT) scan was negative for aneurysm or dissection. The electrocardiogram (ECG) was reported to demonstrate a T-wave inversion in an isolated lead. The creatinine and electrolytes were normal. A brain (or B-type) natriuretic peptide (BNP) was 39. A chest x-ray was unremarkable. He remained stable and underwent a myocardial perfusion imaging exercise test. This was negative and he was discharged. Under review is the inpatient level of care.

The inpatient hospital admission was not medically necessary. This patient presented with chest pain and remained stable. There was hypotension likely due to dehydration which resolved with IV fluids. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection, need for prolonged IV medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, or definitive supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG. in this case, the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of coronary artery disease, septal defect status post implanted occlusion device, and hysterectomy. She presented to the emergency department with sudden-onset epigastric abdominal pain radiating to her back and across the upper abdomen, nausea, and one episode of emesis. Physical examination was notable for a moderately distended abdomen and moderate diffuse abdominal tenderness with guarding.
Lab results were notable for hyperglycemia with glucose of 198 milligrams per deciliter (mg/dL), elevated aspartate aminotransferase of 152 international units per liter (IU/L), elevated alanine aminotransferase of 81 IU/L, elevated lipase of over 20,000 IU/L, and elevated low-density lipoprotein of 133 mg/dL. A urinalysis was notable for trace blood, red blood cells, and few bacteria. A chest x-ray showed cardiomegaly with mild prominence of central pulmonary artery vasculature. An ultrasound of the abdomen showed cholelithiasis with borderline thickened gallbladder wall consistent with acute calculus cholecystitis, borderline dilated common bile duct consistent with choledocholithiasis, and a questionable heterogenous echogenic mass in the right renal lower pole measuring 4.1 centimeters (cm). Computed tomography scan of the abdomen and pelvis was consistent with gallstone pancreatitis, cholelithiasis with biliary sludge, edematous and moderate stranding surrounding the pancreatic body, and heterogenously enlarged right renal lower pole mass measuring up to 4.7 cm. She was treated with intravenous hydromorphone and ondansetron. She was maintained nil per os (NPO). A Gastroenterology consultation recommended aggressive intravenous hydration and magnetic resonance cholangiopancreatography. She had ongoing abdominal pain and no passage of flatus. Lab results showed a lower hemoglobin of 11.1 g/dL, and improved glucose of 113 mg/dL, aspartate aminotransferase of 61 IU/L, alanine aminotransferase of 72 IU/L, amylase of 849 IU/L, and lipase of 5773 IU/L. She decided to leave against medical advice to go to another hospital. The health plan's determination is upheld. The patient had acute pancreatitis [1-3]. She was appropriately treated, with intravenous fluid administration and investigation for a biliary cause for pancreatitis [4]. However, there was a lack of hemodynamic instability, organ failure, pleural effusion, or other sequelae to justify acute continued inpatient care, and the treatment provided could have been provided without the acute inpatient level of care [5]. There was no definitive complication of gallbladder disease or choledocholithiasis such as acute cholangitis, hepatic abscess, or sepsis was discovered, and no other cause for elevated liver enzymes which would warrant the inpatient level of care. [6,7]. Liver enzymes and lipase were improving. For these reasons, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Abscess/infection
Inpatient hospital stay

The patient has a history of diabetes and presented to the hospital. Patient had a chief complaint of facial swelling and also complained of dental pain. The patient reportedly lost a tooth while eating seven days prior to presentation and began having dental pain on the right side of  face with reported swelling. Paitent admitted to having a fever that started intermittently three days prior to presentation. Vital signs showed temperature 97.4 Fahrenheit heart rate 72 respiratory rate 18 blood pressure 171/82. On physical examination, the patient had poor dentition, missing teeth, and right facial swelling. There was no abscess or area of fluctuance. Heart was regular, breath sounds were normal. Labs showed a white blood cell (WBC) 7.2 hemoglobin 13.3 platelets 194 sodium 137 potassium 4.4 creatinine 0.69. A computed tomography (CT) of the facial bones showed no abscess or evidence of osteomyelitis but a 2.1 centimeter (cm) intracranial lesion was identified. The patient was admitted for suspected facial cellulitis and brain lesion. The plan of care included intravenous (IV) antibiotics, infectious disease consult, brain magnetic resonance imaging (MRI), neurosurgery consult, monitor glucose, and continue other home medications. Neurosurgery saw the patient and their impression was that the patient had a likely meningioma. This was later confirmed on MRI. The infectious disease service had concerns for dental abscess and recommended antibiotic changes and evaluation by an oral surgeon. The oral surgeon recommended first completing a course of IV antibiotics. The patient was discharged with instructions to follow up with a dentist to treat the multiple severe dental caries. The health plan's determination of medical necessity is upheld in whole. The patient had facial cellulitis and received IV antibiotics but there was no history of failing oral antibiotics and there was no evidence of hemodynamic instability or bloodstream infection. In addition, there were no other acute complications and the brain finding was incidental and consistent with a benign meningioma. The paitent could have safely and effectively been treated at a lower level of care.
The patient was hemodynamically stable and primarily received antibiotics and a diagnostic evaluation, with both neurosurgery and infectious disease involved. Because of the stability of the presentation and initial diagnostic findings in the emergency department (ED), this patient  could have safely received antibiotics at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Thyroid Cancer
Inpatient hospital

This is a male with a history of papillary carcinoma of the thyroid for which he underwent thyroidectomy 5 years previously. A computed tomography (CT) of the neck confirmed a level II mass and a fine needle aspiration was consistent with papillary carcinoma metastatic to the neck. The patient underwent an uneventful right modified radical neck dissection with no intraoperative complications. His vital signs were stable in the post anesthesia care unit, with no bleeding or hematoma, intolerable pain, nausea or vomiting, and he was hemodynamically stable with no respiratory distress or difficulty voiding. He was admitted. 

The health plan's determination is upheld. The inpatient admission was not medically necessary. This patient underwent a right neck dissection for treatment of papillary carcinoma of the thyroid metastatic to the neck 5 years after thyroidectomy. Modified radical neck dissection (MRND) is defined as the excision of all lymph nodes routinely removed in a radical neck dissection with preservation of one or more non lymphatic structures. He was admitted after an uneventful surgical and postoperative period. The patient remained afebrile in the post anesthesia care unit with stable vital signs, no nausea/vomiting, no respiratory distress, no dysphagia stridor or hoarseness, and no evidence of bleeding or hematoma. He was voiding, and was able to tolerate oral intake. Criteria for an inpatient stay according to Milliman Care Guidelines (MCG) Clinical Recovery Guidelines were not met and an inpatient hospital admission not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The pictures indicate a crossbite of tooth 10.
At issue is the medical necessity of braces for this patient. The health plan's determination is overturned.

The requested service/treatment of Braces is medically necessary. The pictures indicate a crossbite of tooth 10. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) These problems are much more time consuming to correct than the patient's current orthodontic problem. The patient will damage their teeth if orthodontic treatment is not initiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Inflammatory Demyelinating Plyneuropathy (CIDP)
Treatment: Gamunex-C 1 gram/vial 25 mg infused intravenously once weekly for 1 year = 50 units per dose for a total of 2600 units, and HCPCS code S9338
The insurer has denied coverage for Gamunex-C 1 gram/vial 25 mg infused intravenously once weekly for 1 year = 50 units per dose for a total of 2600 units, and HCPCS code S9338
The denial is reversed.
 
The patient is a female currently diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). Per the provider letter, the patient noted weakness, sensory disturbance, gait, and balance difficulty. The patient was diagnosed with CIDP based upon clinical, electrodiagnostic, and nerve tissue findings in the summer. The patient reported that she was currently receiving weekly treatments of Gamunex. The physical examination revealed hypoactive tendon reflexes (TRs), weakness of the legs rated 4-/5, and arms 4/5, with stocking vibratory and cold temperature sensory changes, fasciculation, positive Romberg, and tandem imbalance, with mild tremor and intact MS and CN. A electromyography (EMG) and nerve conduction study (NCS) of the legs and left arm was performed that showed interim changes reflecting persistent CIDP including prolonged distal motor latency, slow motor nerve conduction velocities (MNCVs), temporal dispersion, partial conduction block (CB) and F response prolongation or absence with chronic neurogenic motor unit potential (MUP) changes. A request was made for Gamunex.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired neurological disorder characterized by progressive weakness and impaired sensory function evolving over more than 2 months with associated loss or significant decrease in deep tendon reflexes, and by electrophysiological evidence of peripheral nerve demyelination as shown in the current case. Expeditious diagnosis and treatment of CIDP early in the disease course is critical such that irreversible disability can be avoided. Intravenous immunoglobulin (IVIG) is one first -line and maintenance therapy option for CIDP. Unlike IVIG which requires administration by a health care professional, subcutaneous immunoglobulin (SCIG) can be self -administered by patients in their home. 

The requested Healthcare Common Procedure Coding System (HCPCS) code J1561 Gamunex-C1 gram/vial 25 mg infused intravenously once weekly for 1 year = 50 units per dose for total of 2600 units, and HCPCS code S9338 is considered medically necessary for this patient. The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. This treatment is deemed appropriate and within standard of care guidelines. 

Based on the above, the medical necessity for Healthcare Common Procedure Coding System (HCPCS) code J1561 Gamunex-C 1 gram/vial 25 mg infused intravenously once weekly for 1 year = 50 units per dose for a total of 2600 units, and HCPCS code S9338 is substantiated. The insurer's denial is reversed.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus 
Treatment: Invokana 

The insurer denied Invokana. The determination is upheld. 

This is a patient diagnosed with type 2 diabetes mellitus (T2DM). As reported, she has hypothyroidism. Her hemoglobin A1C was 6.4 %; 7.2 %; 8.2 %. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. 

There are no studies showing superiority of the requested medication, Invokana, over the formulary alternatives. The patient has not tried the formulary alternatives. The formulary alternatives Farxiga, Jardiance are expected to be as effective and have similar side effects to the requested medication. 

The formulary drugs Farxiga (dapagliflozin) and Jardiance(empagliflozin) and the non-formulary drug Invokana (Canagliflozin) are sodium glucose co-transporter (SGLT-2) inhibitors used to treat type II diabetes [1, 2]. SGLT-2 inhibitors are good options for treating diabetes based on the latest American Association of Clinical Endocrinologists recommendations[3-6]. They are at the same level as glucagon-like peptide (GLP) 1 agonists and dipeptidyl peptidase (DPP) 4 inhibitors on the latest American Association of Clinical Endocrinologists (AACE) recommendations[6]. Invokana is Food and Drug Administration (FDA) approved [2] for treatment of type 2 diabetes. It is a sodium-glucose co-transporter 2 (SGLT2) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus(1). Since there are no studies showing superiority of the requested medication, Invokana, over the formulary alternatives, the formulary alternatives can be tried. 

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Postpartum Endometritis, Dilatation and Curettage
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial was reversed.

This is a female patient who presented to the Emergency Department (ED) several weeks after a normal vaginal delivery. Her presenting complaints included fever, vomiting, body aches, and foul smelling vaginal bleeding. The patient's initial vital signs were: low blood pressure of 87/58, elevated pulse rate of 124 bpm, temperature of 102.9. A physical exam was performed that revealed the patient to be ill in appearance, suprapubic and uterine tenderness with a foul smelling discharge. The patient's initial laboratory findings showed elevated white blood cell (WBC) count of 11.4 and low hemoglobin of 9.9 and hematocrit of 29.8. The patient's urinalysis showed presence of proteins, ketones, bilirubin, blood, leukocytes, WBC, red blood cell (RBC), bacteria, and epithelial cells. A pelvic ultrasound was performed that showed retained products of conception. The patient was admitted to the hospital with postpartum endometritis and retained products of conception. The patient was started on intravenous (IV) antibiotics and underwent dilatation and curettage with removal of retained products of conception. The patient was also transfused with 3 units of packed red cells. The patient was medically stabilized and discharged home.

Postpartum endometritis is a common cause of postpartum febrile morbidity (defined as an oral temperature of >=100.4 degrees Fahrenheit or more on any 2 of the first 10 days postpartum, exclusive of the first 24 hours. The infection is polymicrobial, usually involving a mixture of two to three aerobes and anaerobes from the lower genital tract. The diagnosis of postpartum endometritis is based upon clinical criteria of fever and uterine tenderness occurring in a postpartum woman. Other signs and symptoms which support the diagnosis include foul lochia, chills, and lower abdominal pain. In this case, this patient had severe endometritis in addition to retained product of conception and symptomatic anemia. Admission to the hospital for intravenous (IV) antibiotic, dilation and curettage (D&C) procedure and transfusion, as well as ruling out sepsis were all medically necessary. 

According to the MCG guidelines on endometritis, this patient's postpartum endometritis met the criteria for inpatient admission. The treatment is indicated for relief of symptoms and prevention of sequelae. Given the microbiology of these infections, parenteral antibiotics are administered until the patient is clinically improved and afebrile for 24 to 48 hours. Based on the review of the medical record and literature, this patient's admission was medically necessary. Once she was afebrile and clinically improved the patient was discharged home. This was consistent with standard of care.

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 admission is substantiated.  The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was reversed. 

This is a female patient who was admitted to this hospital for detoxification due to withdrawal symptoms. Her symptoms included diarrhea, malaise, yawning, fatigue, teary eyes, sleeping problems, chills, poor appetite, an elevated blood pressure of 145/91, and cravings. She had a Clinical Institute Withdrawal Assessment (CIWA) of 5 and a Clinical Opiate Withdrawal Scale (COWS) score of 6. She had a history of a psychiatric hospitalization. She reported drinking two fifth bottles of vodka per day, using one bag of heroin per day, smoking 5-8 balls of crack per day, and smoking 2 blunts of cannabis per day. She had a positive toxicology for cocaine and cannabis. Her detoxification treatment included the administration of Ativan and Methadone as per protocol. She had no sober supports and could not maintain abstinence. Cardiology and Psychiatry were consulted. The patient had a period of medical stability and was discharge home. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal. The US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting. The risk of delirium tremens can occur 3-4 days after alcohol use; therefore, she was considered at risk for this. 

The health care plan did not act reasonably, or with sound medical judgement, or in the best interests of the patient. 

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

Diagnosis: Dyspnea
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male.  At the time of admission to the hospital, he had past medical history of hypertension (HTN), dyslipidemia, diabetes mellitus (DM) type II, coronary artery disease (CAD) status post (s/p) coronary artery bypass grafting (CABG) in 2008, chronic back pain.  The patient presented to the ED for worsening dyspnea. The patient was hemodynamically stable. Electrocardiogram (ECG) revealed no acute changes. Chest x-ray was consistent with congestive heart failure (CHF). The oxygen saturation by pulse oxymetry was 96% on admission. The patient was placed on bi-level positive airway pressure (BiPAP) overnight and treated with intravenous (IV) Lasix. His home medications were continued. He improved clinically and was discharged home the next day with a plan for outpatient follow-up.

The patient presented with an exacerbation of chronic CHF, consistent with fluid overload. The patient was hemodynamically stable, and had adequate oxygen levels on admission. There was no evidence of acute myocardial infarction, acute coronary syndrome, or arrhythmia. The patient was treated BiPAP and with IV Lasix with clinical improvement, and his outpatient medications were continued. The patient was subsequently discharged in stable condition the next day for outpatient follow-up. Given the presentation and course, as well as known diagnosis, an admission to an acute inpatient setting was not medically necessary, and the management of his acute exacerbation could have been performed in an observation setting in 24-48 hours with outpatient follow-up.