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

Diagnosis: Right Leg Swelling and Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient in this case is an adult male who went to the emergency department with a four-day history of right leg pain and swelling. He had pain when bearing weight. He also complained of shortness of breath with exertion. The patient's vital signs and oxygen saturation were normal. Physical exam was notable for right leg swelling and tenderness. There was abdominal distention. Creatinine was 1.66. Doppler ultrasound revealed acute deep vein thrombosis (DVT) of the right lower extremity. There was evidence of acute kidney injury. The patient was given Lovenox 80 milligrams every 12 hours and was admitted to the hospital. Intravenous (IV) fluids were started, and a computed tomography (CT) of the chest angiogram was planned when creatinine improved. Following admission, acute kidney injury improved with intravenous fluids. Computed tomography (CT) angiogram was done and revealed no pulmonary embolism. The patient was transitioned to Eliquis and was discharged on Day #3. 

The proposed treatment was not medically necessary.

This patient did not require acute care inpatient admission. The patient was treated with intravenous fluids and his acute kidney injury resolved by the day after admission. He had an acute deep vein thrombosis (DVT) but had no threatened limb ischemia. He had no hypoxia, no hemodynamic instability, and no active bleeding. He did not have any signs of coronary ischemia or respiratory failure. The patient could have been managed safely at a lower level of care, such as observation care. The proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee injury.
Treatment: Inpatient Level of Care.
The insurer denied the Inpatient Level of Care.
The health plan's determination is upheld. 

This patient is a male who underwent elective left knee arthroscopy for loose body removal and fixation of an osteochondral fragment on his medial femoral condyle. The records document that this surgery was successful with no documented complications.
At issue is the medical necessity of the Inpatient Level of Care.

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

The requested health service/treatment of Inpatient Level of Care was not medically necessary for this patient.
Documentation shows that this male patient sustained a left knee injury while playing college lacrosse. The injury resulted in a large osteochondral fragment detaching from his medial femoral condyle. Surgery was indicated because the patient had locking of the knee. The operation was completed in which a loose body was removed, and fixation of the osteochondral fragment was completed arthroscopically. This care was consistent with the current standard of care and with the recommendations of the peer-reviewed literature as documented by Bradley and colleagues in the Knee journal in 2022. However, the records do not document any complications requiring the hospital admission. This determination is based upon the recommendations of the peer-reviewed literature as there are no documented complications requiring admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented with concerns of altered mental status and a possible overdose of home medications. The pertinent history included alcohol abuse, depression, anxiety, and bradycardia status/post (s/p) pacemaker placement. Psychiatry consulted and documented no indication for psychiatric hospitalization or need for 1:1 constant observation. The patient was admitted to the hospital with an impression of alcohol intoxication, alcohol abuse, depression, and anxiety. The treatment plan included Clinical Institute Withdrawal Assessment (CIWA), Librium taper, and multivitamins. There were no new issues. Anxiety and tremor were noted. The treatment plan was unchanged with a Librium taper continued. At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient had a history of alcohol abuse and bipolar affective disorder and initially presented with agitation, alcohol intoxication, and possible overdose of home medications. Initial examination documented the patient as agitated with stable hemodynamics and an alcohol level of 285.2. Lorazepam and haloperidol were administered for his agitated state while acutely intoxicated. Psychiatry consulted, ruled out suicidal ideation, and cleared the patient for discharge from a psychiatric standpoint. The treatment plan included intravenous fluids, a scheduled Librium taper, and resumption of home medications. A tremor and anxiety were noted after the intoxication resolved, but no documentation was provided that was consistent with delirium tremens or seizure activity. There was no documented history of repetitive seizures, delirium tremens, or sedative withdrawal. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite. 
Treatment: D8080 Braces, D8680 Monthly Visit x12. 

The insurer denied: D8080 Braces, D8680 Monthly Visit x 12. 
The denial is overturned. 

The patient is a teenage female. The request is for orthodontic benefits with monthly visits. The patient has skeletal Class I and canine class II malocclusion. She also has moderate upper and lower arch crowding with a deep bite. The prior denial was due to a handicapping index score of 12. 

The proposed treatment is medically necessary. 

The patient has an anterior permanent tooth in crossbite with gingival attachment loss and recession of the gum tissue (tooth #22, lower left canine). This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem and the monthly visits are needed to make sure treatment is progressing. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with request for alcohol detoxification. Pertinent history included diabetes mellitus, alcohol use, and smoking crack. No history of alcohol withdrawal seizure or delirium tremens are noted. Initial vital signs revealed a temperature of 97.5F (Fahrenheit), heart rate (HR) 81, blood pressure (BP) 112/71, respiratory rate (RR) 18, and oxygen saturation 100% on room air. Initial examination documented the patient as alert and oriented with evidence of acute intoxication. 

The inpatient hospital admission was not medically necessary. The patient had a history of alcohol use disorder without prior withdrawal seizures or delirium tremens who presented with acute alcohol intoxication requesting detoxification. Initial examination documented the patient as alert, oriented, and with stable hemodynamics. Initial evaluation was relatively unremarkable with the exception of hyponatremia. Treatment included intravenous fluids and CIWA (Clinical Institute Withdrawal Assessment) with benzodiazepines as needed. Following observation care, the CIWA was documented as 0 and no benzodiazepines had been indicated / administered for a 24 hour period. The patient was deemed medically stable for discharge with a similar serum sodium level as on arrival. No other issues or complications were documented. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a female with a history of anemia, dyslipidemia, and abnormal uterine bleeding, who presented to the emergency department (ED) with complaints of vertigo persisting for the past four days. She described a constant sensation of the room spinning around her and noted that this vertigo was accompanied by episodes of palpitations and numbness in her lower extremities. Additionally, the patient reported associated nausea that began the day before of her presentation, along with two episodes of vomiting, one before her presentation and two more in the ED. She indicated experiencing right ear pain over the course of four days and chills that had started three days prior. Importantly, the patient denied experiencing fever, dyspnea, or any recent falls or injuries. 

The inpatient hospital stay was not medically necessary. 
Considering the patient's presentation with vertigo, palpitations, ear pain, and chills, this definitely required further evaluation. However, the absence of central nervous system involvement indicated by both physical examination and imaging studies-showing no signs of stroke, transient ischemic attack (TIA), intracranial bleeding, or encephalopathy-and the lack of severe or incapacitating vertigo, hemodynamic stability, and absence of persistent vomiting or dehydration, along with the absence of underlying serious medical conditions and overall improving clinical symptoms, made the admission for observation the most appropriate course of action. 
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder. 
Treatment: Deep Brain Stimulation. 
The insurer denied Deep Brain Stimulation. 
The determination is upheld. 

This is a male patient with a history of major depressive disorder. He has been on multiple medications without relief. The neurologic exam shows no motor, sensory or reflex abnormalities. The provider has recommended deep brain stimulation (DBS) and this is under review for medical necessity. 
The use of DBS is not medically necessary. The patient has a history of major depressive disorder. While the use of DBS for treatment-resistant depression (TRD) is a promising advance in technology, further testing is needed to show its efficacy. The literature shows this to be a promising technology but further studies are needed. Wu et al cite, "These findings suggest that DBS for TRD is considered promising, which should be confirmed by well-designed and large sample studies. Future basic research and comprehensive clinical trials are needed to reach better understanding on the mechanisms of action and optimal targeted structure". Figee et al cite, "DBS is an effective, safe, and well-tolerated therapeutic option for TRD. Progress in the field may depend on the development of novel outcome measurements capturing the sustained circuit-selective symptom changes observed after DBS, and standardization of randomized placebo-controlled study designs including initial open-label parameter optimization". Hitti et al cite, "While enthusiasm for DBS treatment of TRD has been tempered by recent randomized trials, this meta-analysis reveals a significant effect of DBS for the treatment of TRD. Additionally, the majority of trials have demonstrated the safety and efficacy of DBS for this indication. Further trials are required to determine the optimal stimulation parameters and patient populations for which DBS would be effective. Particular attention to factors including electrode placement technique, patient selection, and long-term follow-up is essential for future trial design". Davidson et al cite, "DBS for treatment-resistant depression (TRD) is a complex and dynamic field. Despite two failed industry-sponsored trials, a randomized controlled trial (RCT), using a patient-specific adaptive design, demonstrated a significant therapeutic effect over placebo. Patient-specific DTI targeting has allowed for novel, sophisticated, circuit-based DBS interventions. DBS trials have yet to account for heterogeneity within MDD. The time is ripe for a novel randomized controlled trial (RCT), which will utilize adaptive trial design, diffusion tensor imaging (DTI)-based targeting, and consideration of depression subtypes".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who initially presented to the emergency department with epigastric abdominal pain, a sore throat, macular rash, chills, cough, and cervical lymphadenopathy. The initial examination documented scleral icterus with a facial macular rash and without significant abdominal findings. An abdominal ultrasound was relatively unremarkable. The patient was admitted to the hospital for concerns of elevated liver enzymes. The treatment plan included supportive care and additional diagnostic testing. Magnetic resonance cholangiopancreatography (MRCP) was unremarkable for choledocholithiasis or other significant pathology Gastroenterology consulted and felt the clinical picture was consistent with a nonspecific viral infection. Repeat laboratory testing revealed improvement in the liver enzymes and the patient was cleared for discharge. At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient presented with abdominal pain, a sore throat, cervical lymphadenopathy, rash and chills. The initial examination documented the patient as alert, afebrile, hemodynamically stable, and without significant abdominal findings. The initial evaluation included elevated liver enzymes without significant pathology on an abdominal ultrasound. The reason for hospitalization was essentially to observe the liver enzyme trend and obtain additional liver imaging. The liver enzymes trended downward, an MRCP was unremarkable, and the patient was cleared for discharge. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met. The patient did not have peritoneal signs, evaluation requiring the patient to not eat or drink for an extended period (more than 24 hours), hemodynamic instability, severe pain requiring acute inpatient management, identification of etiology or finding that requires inpatient care (eg, aortic dissection, bowel perforation, bowel ischemia), signs of intestinal obstruction, suspected toxic megacolon, bacteremia, severe electrolyte abnormalities requiring inpatient care, inability to maintain oral hydration that persists after observation care treatment, or a surgery needed that cannot be performed on ambulatory basis.[2]
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a female who presented with 1 day history of right lower quadrant (RLQ) pain, nausea and fever. The patient was found to have acute uncomplicated appendicitis. The patient was managed non-operatively with intravenous (IV) antibiotics. The patient was discharged home the following morning, tolerating a regular diet and oral pain medication. The patient was discharged home with oral antibiotics. 

The inpatient hospital admission was not medically necessary. This patient is a healthy female who was found to have uncomplicated acute appendicitis that responded to nonoperative management. The patient tolerated a regular diet and was discharged to home with oral antibiotics within an observation period. The patient was clinically stable and able to be discharged home to continue a course of oral antibiotics. At no time was the patient unstable or clinically complex. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Vein Thrombosis
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of hypertension (HTN), cerebrovascular accident (CVA), benign prostatic enlargement (BPE), and chronic lymphocytic leukemia (CLL) who was admitted with complaints of (c/o) left lower extremity (LLE) swelling and pain. His vital signs were notable for pulse 108. Imaging studies included LLE duplex which showed deep vein thrombosis (DVT). The patient was diagnosed with a DVT and treated with enoxaparin, intravenous fluids (IVF), and oncology consultation, who recommended transition to apixaban. The patient's hemoglobin dropped to 6.8 during the hospital stay and he received one unit if packed red blood cells (PRBCs). 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 with LLE swelling and pain, and was found to have LLE DVT. The patient had stable vital signs, no evidence of significant pulmonary embolism, there was no hypoxia, no contraindications for outpatient novel oral anticoagulant (NOAC) or enoxaparin/warfarin therapy, no dyspnea at rest, history of heparin induced thrombocytopenia, history of allergy to NOACs, heparin, warfarin, inability to self-administer enoxaparin, severe unexplained anemia, or bilirubin greater than (>) 2.4 or history of severe liver disease, history of (h/o) a bleeding disorder, history of gastrointestinal (GI) bleeding or documented positive guaiac of stools, recent spinal/brain surgery, indwelling epidural catheter, history of (h/o) recent lumbar puncture, recent stroke, intracranial bleed, aneurysm, or arteriovenous malformations (AVM). The patient did have thrombocytopenia, but oncology cleared the administration of anti-coagulation. The patient did have a hemoglobin drop during the hospital stay, but there was no active bleeding. Overall, this patient received anti-coagulation and monitoring, and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthodontic issues (impacted tooth and crowding). 
Treatment: Braces/monthly visits. 
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a young male with impacted tooth #29. He has 4 millimeter (mm) overjet and 4mm overbite. He is treatment planned for orthodontics (Braces and Monthly Visits) to address the crowding and to create space to bring the impacted tooth into the arch. 

Braces and monthly visits are medically necessary for this patient. Approximately 10% of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. The panoramic radiograph for this patient appears to indicate a high chance that tooth 29 will damage the root of tooth 28 without treatment. If left untreated the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Cubby bed. 
The insurer denied Cubby bed. 
The determination is overturned. 

This is a male patient who has been diagnosed with autism spectrum disorder. He has pica (mouthing and attempted ingestion of non-edible items). According to a letter by his behavior analyst and his pediatrician, he is non-verbal and lacks safety awareness. He has fallen from his bed on several occasions. He is mobile and wanders through the house at night. He is able to open doors and windows, and he is an elopement risk. The patient's family has tried to have him sleep on a mattress on the floor, but he still wanders. 
His behavior analyst and pediatrician recommended a Cubby bed for the patient. The bed is enclosed and is opened on the outside by a caregiver. It has a soft protective interior to prevent entrapment. The bed has circadian lighting to encourage sleep and is equipped with a Bluetooth camera to permit remote monitoring. There is a two-way communication system. 
At issue in this case is whether a Cubby bed is medically necessary for the patient. 

The requested health service/treatment of a Cubby bed is medically necessary for this patient. 
There are very few papers in the medical literature that address the use of enclosed, protective beds, fall risk and pica in individuals with intellectual disability and autism spectrum disorder. The papers referenced are the only relevant papers that the reviewer could find. All are outside a 5-year period. 
In a search of PubMed using search terms "canopy bed", "protective bed" and "enclosed bed" for children, the reviewer was able to find only one paper, [1]. The authors performed a "retrospective chart review of 208 pediatric enclosure bed encounters in an acute care setting over a 2-year period. Variables included demographics, length of stay and bed use, behavioral medications, restraint and sitter usage, skin breakdown, fall risk, and falls." The authors concluded that "Use of the enclosure bed is a reasonable intervention in certain children to ensure their safety." 
The patient also has pica-mouthing or ingestion of non-edible items. "Pica is a dangerous form of self-injurious behavior that occurs in people with developmental disabilities [3]." The disorder can lead to airway compromise and death. 
A Cubby bed is medically necessary for this patient, who has autism spectrum disorder. He is a fall risk and has pica. Both conditions could place him at risk of severe injury or death. An enclosed, Cubby bed will provide a safe, protective environment for sleep, and also allow his caregivers to sleep.