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

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

The patient is a female with a 5 week history of L (left) buttock and leg pain. She had associated numbness and decreased foot strength as well. PSH (past surgical history) was significant for prior L (lumbar)5/S (sacral)1 micro-lumbar decompression.  

An inpatient hospital admission was not medically necessary. Although the patient had slow progress with physical therapy (PT), this could have been provided at a lower level of care than inpatient. She does not meet inpatient criteria. The standard of care is to perform this procedure as an outpatient procedure. Inpatient stay may be needed for older patients, dural tear, hemorrhage or nerve root injury. None of these circumstances occurred in this patient. The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Pharmacy/Prescription Drug

Diagnosis: Tourette Syndrome 
treatment: Austedo
The insurer denied Austedo. The health plan's determination is upheld. 

The patient is a male with Tourette Syndrome and epilepsy. His epilepsy is well controlled on Keppra. However, the tics that he has because of his Tourette Syndrome are not well controlled. He has motor tics and vocal tics. His motor tics include eye movements, shoulder movements, neck flexion and extension, nose and mouth movements, and breath holding. His vocal tics include squeaks. He is very bothered by his tics, especially the neck movements and breath holding. 

Austedo is not medically necessary for this patient. Austedo is deutetrabenazine, a VMAT2 (vesicular monoamine transporter type 2) inhibitor that affects dopamine function in the brain. Austedo is Food and Drug Administration (FDA) -approved for patients over the age of 18 years who are diagnosed with Huntington's chorea or from Tardive dyskinesia. Austedo is not known to be safe for children under the age of 18, nor is it known to be effective for the treatment of tics in Tourette Syndrome. There have been no placebo-controlled double blind studies examining the safety or efficacy of Austedo for children with Tourette Syndrome. Therefore, it is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post knee surgery.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male with a past medical history significant for arthritis, hypothyroidism, and hyperlipidemia. He was diagnosed with aseptic loosening of a left total knee arthroplasty that had been performed last year. The patient was noted to have intraoperative hypotension, which resolved during the procedure. Per the admission note, the patient reported his pain is a 0 (zero). No chest pain or shortness of breath was noted. No nausea vomiting diarrhea or constipation was noted. The patient 
underwent a left total knee revision. There is a denial letter that notes that the patient had knee surgery. The letter notes that there were no problems with the procedure, and that the patient was discharged the next day. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The inpatient admission was not in accordance with the generally accepted standards of medical practice. The inpatient admission was not clinically appropriate, in terms of its type, frequency, extent, site and duration and considered effective for the patient's injury and pathology. There is nothing in the documentation to suggest the admission was mainly for the convenience of the doctor or other healthcare provider. Based on the records provided, there is no documentation that the patient's medical condition or health would have been significantly and directly threatened if care were to have been provided in a less intensive setting of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Use Disorder
Treatment: Substance abuse inpatient rehabilitation admission
The health plan denied substance abuse inpatient rehabilitation admission.
The determination is upheld.

This is a male patient with a history of substance use disorders including cocaine, marijuana, and alcohol. The patient received substance abuse inpatient rehabilitation level of care. The patient denied any history of seizures, blackouts, or overdose.

The patient denied any suicidal or homicidal ideation or history of suicide attempts. He denied any recent hospitalizations. There was no prior psychiatric history and the patient denied any past medical problems. A urine drug screen was positive for cannabis and cocaine but the blood alcohol content was zero upon admission. The clinical note describes the patient as participating in motivational interviewing. The patient reported no increase in symptoms of withdrawal or uncomfortable feelings. There was no evidence of a severe mood or anxiety problems during the session and there was no suicidal or homicidal ideation, intent, or plan. The mental status exam on admission was within normal limits. At issue is the medical necessity of substance abuse inpatient rehabilitation admission.

In reviewing the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) admission tool, the patient had no immediate need for hospitalization for a life-threatening medical condition or severe psychiatric crisis. Alcohol was the substance with the greatest potential for harm to self or others. The patient met criteria for alcohol use disorder and was not in remission. The patient was no longer at risk for withdrawal given the length of time that had passed since the prior last drink. The patient did not have serious medical or psychiatric symptoms that required inpatient rehabilitation. Clinical documentation does not establish that the patient had recently been using substances and hazardous situations or in amounts or frequencies likely to imminently cause harm to self or others. The patient did have interpersonal deficits including problems maintaining stable relationships and employment. The patient did not exhibit predatory behaviors. There was no evidence of strong cravings or behavioral or emotional instability. Based on responses, the LOCADTR Level of Care is rehabilitative services in a residential setting.

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

Diagnosis:  Impacted tooth.
Treatment:  CT (computed tomography) scan (D0367) and General Anesthesia (D9223) Each 15 minutes x 2.

The insurer denied: CT (computed tomography) scan (D0367) and General Anesthesia (D9223) Each 15 minutes x 2.  The denial is overturned.

The patient is an adult male. The patient was seen by an oral and maxillofacial surgeon, who determined that the patient would benefit for removal of an impacted lower left wisdom tooth #17. 

Pre-determination was requested for removal of the tooth under IV (intravenous) anesthesia and a CBCT (cone beam computed tomography) image.  Initially all treatment was denied by the health plan. A subsequent letter from the health plan then approved removal of the tooth plus 2 units of general / deep sedation, i.e., 30 minutes.  Additional anesthesia time was denied by the health plan, as was the request for a CBCT (cone beam computed tomography) image.  They were denied coverage by the health plan as not medically necessary. The denial is being appealed.

The requested CT (computed tomography) Scan (D0367) and General Anesthesia (D9223) Each 15 minutes x 2 is medically necessary.

The image shows an impacted tooth with fully developed roots that lie in close proximity to the inferior alveolar nerve. In an adult patient, it is often difficult to make a determination by panoramic image of the exact position of the roots to the nerve.  It is well within the standard of care to obtain a CBCT (cone beam computed tomography) image to assist, as this will allow the surgeon to determine how they will approach the surgery, and if it may be more prudent to do a coronectomy rather than a complete removal of the tooth.  Furthermore, only the surgeon can determine how long the procedure can / will take, and the actual time will be reflected in the anesthesia record.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.

Treatment: Inpatient admission .

The insurer denied coverage for an Inpatient admission.

The denial is upheld.

This is a patient with a history of diabetes mellitus (DM), hypertension, anemia, and chronic kidney disease. The patient presented to the emergency room (ER) with pain in the back and chest. The patient was hemodynamically stable, non-hypoxic, and labs showed a hemoglobin of 6.2 and otherwise normal. The patient was given transfusions and was admitted. The inpatient stay is under review.

This patient had anemia and pain without hemodynamic instability. This could have been managed in observation level of care. As this patient had a condition that could reasonably be expected to stabilize within 24 hours, observational status would be appropriate, and the inpatient admission is not considered medically necessary.

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 gastrointestinal (GI) Bleed due to gastroesophageal reflux disease (GERD)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a male with a history of mental health problems, diabetes, kidney disease, hypertension, gastroesophageal reflux disease (GERD), hepatitis C, constipation, and polysubstance abuse. He presented to the emergency room with suicidal ideation, abdominal pain, nausea, and vomiting some blood. He had not taken his medications for the past three days. The vital signs were normal and he was alert and oriented. The physical exam was non-contributory. Labs were remarkable for a white blood cell (WBC) count of 14,800, glucose 251, creatinine 2.4, potassium 5.4, ethanol 2.3, and a urine drug screen positive for cocaine. The chest x-ray was unremarkable, and the abdominal computed tomography (CT) scan revealed a fatty liver and possible constipation. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. He was treated with intravenous fluids, Zofran, and Protonix. The patient was admitted for further treatment and evaluation.

The health plan's determination is upheld.

The requested inpatient hospital admission was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no evidence of ongoing significant gastrointestinal (GI) bleeding, hemodynamic instability, or severe metabolic disarray. The elevated creatinine and hyperkalemia corrected quickly with straightforward treatment. The services provided - intravenous fluids, Protonix, oral medications - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal Ideation
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a male with a history of mental health problems, diabetes, kidney disease, hypertension, gastroesophageal reflux disease (GERD), hepatitis C, constipation, and polysubstance abuse. He presented to the emergency room with suicidal ideation, abdominal pain, nausea, and vomiting some blood. He had not taken his medications for the past three days. The vital signs were normal and he was alert and oriented. The physical exam was non-contributory. Labs were remarkable for a white blood cell (WBC) count of 14,800, glucose 251, creatinine 2.4, potassium 5.4, ethanol 2.3, and a urine drug screen positive for cocaine. The chest x-ray was unremarkable, and the abdominal computed tomography (CT) scan revealed a fatty liver and possible constipation. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. He was treated with intravenous fluids, Zofran, and Protonix. The patient was admitted for further treatment and evaluation.

The health plan's determination is upheld.

The requested inpatient hospital admission was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no evidence of ongoing significant gastrointestinal (GI) bleeding, hemodynamic instability, or severe metabolic disarray. The elevated creatinine and hyperkalemia corrected quickly with straightforward treatment. The services provided - intravenous fluids, Protonix, oral medications - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

 
The patient had a history of a gastric bypass and presented with abdominal pain, nausea, and vomiting. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. A  computed tomography (CT) scan showed enterocolitis. She was diagnosed with a gastroenteritis. Proton pump inhibitor (PPI) therapy and antiemetics were given. Stool testing was obtained. An endoscopy revealed gastritis.

Clinical indications for admission for Gastroenteritis per Milliman Care Guidelines (MCG M-170) include having a severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetic therapy, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Gastritis (MCG M-560) include gastric outlet obstruction, perforation, peritoneal signs, severe vomiting, severe dehydration, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had gastroenteritis and was found on endoscopy to have gastritis. Intravenous (IV) hydration, antiemetics, and PPI therapy could have been given with observation status. She did not meet MCG criteria for admission for either Gastroenteritis or Gastritis. 

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lumbar (L) 5 - sacral (S) 1 discectomy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case involves an adult under review for inpatient hospital admission. The hospital records reported the patient underwent lumbar spine surgery. The preoperative anesthesia report indicated the patient had an American Society of Anesthesiologists (ASA) classification of 3. The appeal letter reported the patient was admitted to a Medical - Surgical floor for diagnosis of lumbar (L)5- sacral (S)1 discectomy. The patient underwent lumbar microdiscectomy and was under anesthesia for approximately 214 minutes. The patient required inpatient admission due to risk level. The determination letter reported the hospital inpatient admission was denied as there was no reported complications and the patient remained stable and was able to go home on the same day.

In this case, the patient underwent lumbar decompression surgery. The patient was discharged home on the same date of service. There was a lack of documentation of any complications with surgical intervention. Lumbar discectomy is an ambulatory procedure and would not require inpatient admission. As such, the prior denial is upheld.

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Obesity
Treatment: Pharmacy/Prescription Drugs

Diagnosis: Endocrine/Metabolic/Class II Obesity
Treatment: Pharmacy/Prescription Drugs/Wegovy
The health plan denied the requested prescription medication, Wegovy, as not medically necessary. The health plan's determination is overturned.

This is a  female with obesity and pre-diabetes. Her body mass index (BMI) is 35. She was seen with a weight of 219 pounds. The patient worked hard at making lifestyle changes and her follow up weight was 215 pounds with reading labels, applying carbohydrate counting, controlling portions, and exercising most days of the week. She was seen in follow up by nutrition with a weight of 213 pounds and by her physician with a weight of 216 pounds, and a body mass index of 35.5. 
The request for Wegovy is under review for medical necessity.

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

Wegovy is medically necessary. This request is for Wegovy for the treatment of obesity. Per the Novo Nordisk website, "all dose strengths of Wegovy are now available to retail pharmacies nationwide." The Endocrine Society Guidelines on the management of obesity indicate that diet, exercise, and behavioral modification should be included in obesity management and pharmacotherapy can be used as an adjunct to these measures, as drugs may amplify adherence to behavior change and may improve physical functioning. These guidelines indicate that patients who have a history of being unable to successfully lose and maintain weight loss and who meet label indications, are candidates for weight loss medications. The patient has tried and failed increased activity and healthy eating with very little weight loss, despite multiple visits with a nutritionist. This patient is obese with a body mass index of 35.5. An additional month of lifestyle changes alone will not reasonably allow a patient to reach a goal of a BMI of less than 30. Without Wegovy, this patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes, particularly given this patient has prediabetes. Therefore, the requested Wegovy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

Diagnosis: nausea/vomiting/abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with medical history of antiphospholipid syndrome on aspirin, arthritis, hyperlipidemia, hypothyroidism, fibromyalgia, migraines, endometriosis, posttraumatic stress disorder, and anxiety. She presented to the emergency department with nausea and vomiting for 10 days, and mild cramping abdominal pain. 

The inpatient hospital admission was not medically necessary. The patient presented with symptoms and imaging consistent with colitis, and then HIDA scan consistent with cholecystitis. However, she did not have evidence of ascending cholangitis, gallstone pancreatitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care. Additionally, there was no persistent hemodynamic instability or other complications. The patient did have an uncomplicated cholecystectomy during the stay, and did not experience postoperative complications such as pneumonia, sepsis, or bile leak which might require the inpatient level of care. There was no contraindication to performance of imaging and then cholecystectomy after presentation. Although imaging showed possible colitis, she was not found to have complications such as toxic megacolon, severe gastrointestinal bleeding, or bowel perforation. The standard of care for the evaluation of and treatment of colitis was appropriately performed, including intravenous fluids and empiric antibiotics. The interventions performed, including labs, monitoring, imaging, empiric antibiotics, specialist consultations, and laparoscopic cholecystectomy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower abdominal pain, Kidney stone
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented with complaints of severe lower abdominal pain. Associated symptoms include nausea and vomiting. He was afebrile and hemodynamically stable. Lab results showed leukocytosis and an elevated creatinine. He was admitted to the hospital and had stent placement the next day. He had an uneventful hospital stay and was discharged home that day. At issue is the medical necessity of an inpatient stay.

No. The inpatient stay was not medically necessary. A majority of patients who present with renal colic can be discharged within 24 hours of presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis; it was done the next day. The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. A lower level of care for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.