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

Diagnosis: Multinodular goiter.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The health plan's determination is overturned.


The patient has a history of hypertension, a kidney stone, and multinodular goiter now status post total thyroidectomy. During the surgery, the patient was noted to have an enlarged gland requiring extensive dissection and a drain placement. Postoperatively, the patient was noted to have an elevated parathyroid hormone (PTH) and calcium. Because of this elevated lab value, the patient was taken back to the operating room for exploration for a parathyroid adenoma. The patient underwent removal of a right superior parathyroid adenoma during the procedure resulting in a decrease of the PTH to 35 postoperatively. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The requested heath service/treatment, inpatient stay, was medically necessary. Appropriate medical care in this case, for the patient, was admission for monitoring the airway evaluation of post-operative bleeding (given the patients history of hypertension). These complications following removal of a large goiter are known and well documented. (Chen et al, 2014, Abboud et al 2010, Berri T, Houari R. 2013). Close monitoring of the airway is needed after removal of a large goiter.
The surgeon's judgement in assessing the patient's hypertensive state and the presence of a large goiter placed the patient in a higher risk category requiring more intensive monitoring. In terms of bleeding being higher in thyroidectomy patients, there is a recent article by Morton and Vandal (2015) giving support to this. They stated that "there was a 39% increase in risk of bleeding for every 10 points rise of highest blood pressure recordings in our patient population (odds ratio [OR] 1.39; 95% confidence interval [CI] = 1.09-1.8)
Furthermore, a parathyroidectomy immediately following total thyroidectomy is extremely uncommon. The patient had a significantly elevated PTH with a substantial drop post-operative in the PTH level. This placed the patient at another increased risk for complications. (Kidwai et al 2020). These authors found that patients with a larger intraoperative decrease in PTH levels (greater than 90.7% drop at 20 minutes), higher preoperative hypercalcemia (greater than 11 milligrams per deciliter (mg/dL)), and higher preoperative PTH levels (greater than 129 picograms per millililter) were more likely to experience a non-routine outcome during outpatient parathyroidectomy. Therefore, the inpatient admission was indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung injury
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who presented to the emergency room with fever and fatigue. He had failed outpatient treatment for pneumonia.

The patient's CXR (chest x-ray) showed multi focal pneumonia with high procalcitonin levels, as well as other inflammatory cytokine markers. The patient was admitted to acute in hospital level of care for possible vaping induced lung injury, as well as possible COVID-19 pneumonia. The patient was started on IV (intravenous) steroids and IV antibiotics.

No, the Inpatient Admission was not medically necessary.

The patient was admitted to acute in hospital level of care for possible vaping induced lung injury as well as possible COVID-19 pneumonia. The patient was started on IV steroids and IV antibiotics. At the time of admission, the patient was not in any distress. The patient was not on oxygen. The patient's vitals were stable. The patient was ambulating and tolerating diet. The patient's condition improved significantly within 24 hours, and IV steroids as well as IV antibiotics could have been switched to oral. The acute inpatient level of care was not medically necessary, as the patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alpha-1 antitrypsin deficiency (AATD)
Treatment: Prolastin-C 1000 MG 
The insurer denied the Prolastin-C 1000 MG.
The determination is upheld.

The patient is a never smoker, with a history of alpha-1-antitrypsin deficiency (PiM/Q0clayton) with the most recent alpha-1 antitrypsin (AAT) serum concentration level of 81.7 milligrams per deciliter (mg/dL). She has a forced expiratory volume in one second ( FEV1) of 109% of predicted. There is no computed tomography (CT) chest or chest x-ray evidence of emphysema. At issue is the medical necessity of Prolastin-C 1000 milligrams (MG).
The requested health service/treatment of Prolastin-C 1000 MG is not medically necessary for this patient. Per the clinical information, the patient has a PiM/Q0clayton genotype alpha 1-antitrypsin (AAT) deficiency, a baseline alpha 1 antitrypsin serum concentration of 81.7 mg/dL, is a never smoker, does not have emphysema as demonstrated on CT chest and has normal pulmonary function testing with an FEV1 of 109% predicted.
The current American Thoracic Society (ATS) and European Respiratory Society (ERS) statement on the diagnosis and management of AAT deficiency does not recommend augmentation therapy for patients with heterozygous phenotypes whose plasma AAT level exceeds 11 micromoles per liter (mol/L) (corresponds to 80 milligrams per deciliter (mg/dL) measured by radial immunodiffusion), such as in this patient. In addition, the ATS/ERS guidelines further state, benefits in individuals with no airflow obstruction, such as in this patient, are less clear. For this patient, the request was for Prolastin-C to reduce the decline of lung function (eg. FEV1). At this time, there is limited evidence that supports the hypothesis that AAT augmentation therapy slows the deterioration of lung function.  
It is not reasonably expected to prevent an illness or expected reduce/improve developmental effects of an illness and is not considered generally accepted standard of medical practice per the literature/national guidelines. Therefore, it would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Short Stature
Treatment: Pharmacy/Prescription Drugs (Nutropin AQ)
The health plan denied the requested prescription medication. The health plan's determination is overturned.

This is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin AQ. Her growth hormone (GH) stimulation  peaked at 15.2. She was found to have a 46 XX Karyotype. Her bone age was 5 years at chronological age (CA) 6 years 9 months. Her Insulin-like Growth Factor 1 (IGF1) was 95.8 and IGFBP 3 (Insulin-Like Growth Factor-Binding Protein 3) was 3.65. No SHOX (Short Stature Homeobox) testing was completed. Her breasts and genitourinary (GU) were at Tanner 1. Her bone age was 6 years 9 months at CA 7 years 11 months. Her height velocity is reported to be 4.96 cm (centimeters) /year.

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

Yes. The requested health service/treatment of Nutropin AQ is medically necessary for this patient. 

The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history (PMH) of gastroesophageal reflux disease (GERD), asthma and gastritis and was admitted with complaints of (c/o) epigastric pain associated with nausea and improved with omeprazole. Vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), abdomen soft/not distended (ND), epigastric discomfort to deep palpation, no guarding or rigidity. The lab work was unremarkable. A computed tomography (CT) scan of the abdomen showed mild gastritis and a right upper quadrant (RUQ) ultrasound (US) showed no biliary dilation or cholelithiasis. The patient was diagnosed with gastritis and treated with intravenous (IV) fluids, anti-emetics, a proton pump inhibitor (PPI) and gastroenterology (GI) evaluation. GI recommended an esophagogastroduodenoscopy (EGD), but the patient left against medical advice (AMA). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care.

This patient presented to the emergency department (ED) with c/o abdominal pain associated with vomiting. She did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. The patient did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, all vital signs were stable, did not have acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with mild gastritis, was treated and responded to intravenous fluids (IVF), anti-emetics, a PPI and GI evaluation, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency deprtment (ED). Complaints were listed as dyspnea on exertion for two days, and left sided chest pain. Risk factors include hypertension hyperlipidemia and gastroesophageal reflux disease (GERD). She was given an aspirin (ASA) and underwent an evaluation for possible acute coronary syndrome (ACS). 

Electrocardiogram (EKG) and cardiac enzymes trended negative.  Nuclear stress test was negative for coronary artery disease (CAD).  Chest x-ray (CXR) was normal and an echocardiogram revealed normal left ventricular (LV) function. The patient was initially hypertensive, but that resolved with oral medications including Lopressor and Protonix.  She was discharged later that same day resuming her oral medications.

No, the proposed inpatient admission was not medically necessary.
In this case, no care or treatment required an inpatient level of care.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam (blood pressure [BP] normalized) and cardiac findings were normal. Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia ("abnormal EKG" was borderline). Chest x-ray (CXR) was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was negative for coronary artery disease (CAD). The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous (IV) nitroglycerin (NTG).  

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of coronary artery disease (CAD). All tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a very low probability), one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute lumbar radiculopathy.
Treatment: Inpatient Hospital Admission.
The insurer denied coverage for the Inpatient Hospital Admission.
The denial is upheld. 

This is a female patient with a history of hypertension, hyperlipidemia, diabetes, asthma, uterine cancer, and a "pinched nerve" that had failed conservative treatment.  She presented to the emergency room (ER) with complaints of lower back and left lower extremity (LLE) pain. She was unable to ambulate.  Imaging revealed L3-L4(Lumbar bones 3 and 4) adjacent disease with severe stenosis and obliteration of the spinal canal.  There is L3-L4 instability with greater than 50% disc collapse with segmental kyphosis and scoliosis.  The patient has failed medical management and surgery was offered.  The patient was admitted with acute lumbar radiculopathy.  She was medically optimized for surgery. Intravenous (IV) Dilaudid and steroids were given.  She underwent an L3-L4 direct lateral decompressive discectomy with interbody fusion with no complications.  Back pain, radiculopathy, and LLE pain resolved.  After surgery the patient was out of bed (OOB) and ambulating well. She was passing flatus and tolerating oral (PO) intake.  She was discharged home with instructions to follow up with the surgeon on an outpatient basis. 

The medical record denotes the patient has chronic back pain.  She was receiving treatment from her Neurosurgeon prior.  He recommended she go to the ER for additional treatment.  She was ambulatory with a limp.  Her pain level was 2/10.  There was no change in her neurologic status.  Her surgical procedure was non-complicated.  There was limited to no blood loss.  She had a satisfactory post-operative course.  Her vital signs were stable.  She had no evidence of bleeding, infection, or intolerable pain.  She was able to tolerate oral medications.  There were no extenuating circumstances to warrant the acute level admission.  Observation level would be applicable. 

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

The carrier's denial of coverage for the Inpatient Hospital Admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumomediastinum.

Treatment: Inpatient Admission.

The insurer denied coverage for the Inpatient Admission.

The denial is upheld. 

This is a male patient with history of asthma who presented to Urgent Care with complaints of chest discomfort.  He was diagnosed with asthma exacerbation and given a steroid shot and bronchodilator (BD) and discharged home.  Later he was called and told to go to the Emergency Department (ED) as his chest x-ray revealed pneumomediastinum.

The patient complained of some dry cough.  There was no fever or chills.  Vital signs in the emergency department (ED) at presentation were temperature (T) 98, heart rate (HR) 79, respiratory rate (RR) 20, blood pressure (BP) 133/72 and oxygen (O2) saturations 98 % on room air (RA).  The patient was in no acute distress (NAD).  He was speaking in full sentences.  Crepitus was noted over right (R) chest wall.  The patient was also noted to have diffuse wheezing.  The patient was alert and oriented x3.  The patient had a non-focal neurological exam. A Computed Tomography (CT) scan of the Chest was done which confirmed pneumomediastinum. White blood cell (WBC) count was 12,000.  Hemoglobin (Hb) was 14.

The patient was admitted to the hospital.  The patient was placed on intravenous (IV) Zosyn, bronchodilator (BD) and intravenous (IV) fluids.  The patient continued on BD via nebulizers and maintenance asthma medications.  The patient was seen by Thoracic surgery who recommended an esophagogram to rule out esophageal perforation.  An esophagogram was done which did not reveal any esophageal tear/perforation.

The patient remained stable overnight.  He was afebrile and hemodynamically (HD) stable.  Symptoms had improved.  The patient denied any shortness of breath (SOB).  O2 saturations were 96-100% on room air.  Repeat chest x-ray revealed decrease in pneumomediastinum.  The patient was tolerating oral intake (PO).

The patient was subsequently cleared for discharge home on oral medications with follow-up in an outpatient setting.

This patient did not need acute inpatient hospitalization.  He could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient could have had the esophagogram done and once negative for perforation the patient could have been discharged home with outpatient follow-up.  The patient was afebrile and hemodynamically stable.  He was not hypoxic.  He had an uncomplicated pneumomediastinum with no evidence of pneumothorax.  

The health plan acted reasonably with sound medical judgement.

The carrier's denial of coverage for the Inpatient Admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Hospital admission.
The insurer denied coverage for the hospital admission.
The denial is upheld. 

This is a male patient with a past medical history notable for coronary artery disease, prior coronary stenting, pulmonary embolism, congestive heart failure, and ischemic cardiomyopathy. He presented to the emergency department with complaints of left-sided chest pain, shortness of breath, dizziness, and nausea. Physical examination was unremarkable. He was hypertensive upon arrival, with blood pressure 167/101. Troponin and N-terminal pro B-type natriuretic peptide (NT Pro BNP) levels were negative. Electrocardiogram (EKG) demonstrated sinus bradycardia with sinus arrhythmia, with T-wave inversions in leads V5-V6, which were felt to be unchanged from the prior EKG. Chest x-ray (CXR) showed clear lungs. He was admitted and ruled out for myocardial infarction. No additional diagnostic cardiovascular testing was performed. His blood pressure improved with re-initiation of his blood pressure medications. He was deemed safe and appropriate for discharge after a period of medical stability, with instructions to follow-up with his physician as an outpatient. 

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

The patient presented with complaints of chest pain, shortness of breath, dizziness and nausea. He has a history of prior coronary artery disease and coronary stenting. His symptoms were concerning for a cardiac etiology. The patient underwent appropriate initial evaluation in the emergency department, which was unremarkable. This included a normal physical exam, a non-diagnostic EKG and negative cardiac troponins. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Cardiac specific troponins remained negative. 

The carrier's denial of coverage for the hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Cardiac
Inpatient hospital

Diagnosis: symptomatic sinus node disease
treatment: inpatients stay

The insurer denied the inpatient stay. The health plan's determination is overturned in part. A one-day stay was medically necessary. 

The patient is a woman with hypertension and atrial myxoma, status/post (s/p) excision, who presented to the emergency room (ER) with a one week history of headaches, mental fogginess, and lightheadedness. She had no chest pain, palpitations, nausea or vomiting. Her blood pressure was 143/65 mm Hg, pulse 37 beats per minute (bpm) and respirations 12. Pulse oximetry was 99% on room air.
She was admitted to the Intensive Care Unit (ICU), evaluated by Cardiology, and underwent placement of a dual chamber pacemaker for treatment of symptomatic sinus node disease. The procedure was uncomplicated, and she was discharged.

A one-day inpatient stay was medically necessary. The patient presented with hemodynamically unstable bradycardia, with heart rates in the 30's, associated with weakness, lightheadedness and headaches. An inpatient hospitalization and pacemaker implantation was indicated. The procedure could have been done the day after admission and the patient discharged as such. The pacemaker procedure and post-operative course were uncomplicated and discharge was appropriate at this point.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scooter accident; C6 transverse process fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who sustained a scooter accident with loss of consciousness. The patient was a level II trauma. Exam revealed antigravity in all extremities. Computed tomography angiogram (CTA) of the neck showed a C6 transverse process fracture.

No, the inpatient admission was not medically necessary.

There is insufficient evidence provided to support the acute inpatient level of care. The patient was cleared by neurosurgery, had no complaints of severe pain or other issues that would require acute inpatient stay (uncontrolled pain requiring intravenous [IV] medication, neurological deficit, weakness or sensory deficit). Therefore, the acute inpatient level of care is not medically necessary.

The health plan acted in the best interest of the patient. The acute inpatient level of care was not appropriate or needed for this patient. The records do not demonstrate any finding that would warrant the patient be admitted overnight for the trauma that he sustained.