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

Diagnosis: ovarian cyst
treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a female who underwent a laparoscopic left ovarian cystectomy that was converted to an open cystectomy. The surgery was converted to an open procedure because of the size and nature of the cyst. The night prior to the procedure, the patient had presented to the emergency department with intractable pelvic pain. An 8 centimeter (cm) simple ovarian cyst without torsion was reported on ultrasound. The patient was added on to the operating room (OR) schedule to have a laparoscopic ovarian cystectomy late in the day. 

The inpatient stay for this patient after open ovarian cystectomy is medically necessary. The standard for a laparotomy is a one to two day stay in the hospital (some literature puts the average at 3 days), commanding an inpatient level of care. There is no literature or basis in current practice for ambulatory or overnight observation discharge of patients after gynecologic laparotomy. These incisions generate a significant amount of pain, requiring medication and nursing assistance that just cannot be provided at home.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: hip pain
Treatment: Ultrasound (US) Guidance for Injection 
The insurer denied Ultrasound (US) Guidance for Injection 
The health plan's determination is upheld.

The patient is a male who was injured when they were training for a marathon, running 30 miles per week. The injured worker has been diagnosed with iliopsoas bursitis, right hip. This is a request for ultrasound guidance for injection. A magnetic resonance imaging (MRI) of the right hip shows trace right iliopsoas bursitis without tear, nondisplaced tear of the right anterior superior quadrant labrum, no fracture, and no hip joint effusion. A progress note indicates that the patient is presenting for right hip ultrasound-guided psoas injection.

The ultrasound (US) guidance for injection is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.
As noted in the article from Journal of ultrasound medicine, the treatment for iliopsoas tendinopathy includes ultrasound-guided iliopsoas corticosteroid injections; however,' evidence is lacking regarding ultrasound-guided iliopsoas injection efficacy. Ultrasound-guided iliopsoas corticosteroid injections improved outcomes regardless of coexisting hip abnormalities and may advance short-term care and help continue with nonsurgical treatment regimens. As noted in the article from arthroscopy, ultrasound-guided diagnostic injections into the iliopsoas bursa can be helpful in differentiating the source of the pain.
In this case, the patient has trace right iliopsoas bursitis without tear phone on MRI. They were training for a marathon and developed anterior hip and groin pain. There is pain with resisted hip flexion on physical examination. They have tried physical therapy and topical non-steroidal anti-inflammatory drugs (NSAIDs). Given there were no significant tendinopathy or tear of the iliopsoas tendon, and the medical literature available for iliopsoas bursitis ultrasound guided injections is not strong enough, the ultrasound-guided injection for iliopsoas bursitis is not indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: hip pain
Treatment: Ultrasound (US) Guidance for Injection 
The insurer denied Ultrasound (US) Guidance for Injection 
The health plan's determination is overturned. 

This is a male patient diagnosed with right iliopsoas bursitis. There is a request regarding ultrasound-guided guidance for injection. A progress note documents that the patient presented for an ultrasound guided psoas injection. They are training for a marathon and running 30 miles a week. They report anterior hip and groin pain. A magnetic resonance imaging (MRI) documented trace right iliopsoas bursitis. An exam of the right hip documented tenderness with resisted hip flexion. An ultrasound guided injection of corticosteroid was provided to the psoas tendon sheath/bursa.

The ultrasound guidance for injection was likely to be more beneficial than injection without ultrasound guidance for the treatment of the patient's iliopsoas bursitis. The below article in the Journal of ultrasound indicates that studies show ultrasound guidance for procedures about the hips improve safety, efficacy, and accuracy compared to landmark guided injection. Additionally, the below review article in the Journal of the American Academy of orthopedic surgeons states that the proximity of the hip to important neurovascular structures, lack of palpable anatomic landmarks, and deep location targets can make ultrasound-guided injection is ideal.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: hip pain
Treatment: Ultrasound (US) Guidance for Injection 
The insurer denied Ultrasound (US) Guidance for Injection 
The health plan's determination is overturned. 

This case describes a male patient with a complaint of right hip pain. A magnetic resonance imaging (MRI) scan was obtained by the patient's orthopedic provider which revealed iliopsoas bursitis without evidence of tendon tearing. The patient followed up with the orthopedic provider who offered and performed an ultrasound guided iliopsoas injection for the patient's right hip. The patient's health plan denied coverage for the ultrasound guided hip injection.

The proposed Ultrasound (US) Guidance for this patient's iliopsoas hip injection was likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The provided medical records document that this male runner was preparing for an upcoming marathon race and disabling hip pain secondary to iliopsoas bursitis that was confirmed clinically and on MRI scan. The provider performed an ultrasound guided ilipsoas bursa injection to treat this patient's pathology. This injection was likely to be more beneficial than any standard treatment for iliopsoas bursitis based upon the conclusions of the peer-reviewed literature as documented by Han and colleagues in 2019.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral vascular disease.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female who presented to the hospital for evaluation of bilateral lower extremity lifestyle limiting claudication, R>L (right greater than left) and resting pain. The patient previously was scheduled for staged iliac revascularization which was cancelled due to recent hospitalization for infection of foot ulcer and pneumonia.
The patient presented for peripheral angiogram with possible percutaneous transluminal angioplasty (PTA).

Inpatient Hospital Admission was not medically necessary for this patient. The patient presented for elective, schedule intervention of her ischemic lower extremity. The patient had known PVD (peripheral vascular disease) and non-healing ulcer. The patient previously underwent noninvasive and invasive assessment of lower extremity (LE) circulation. The patient underwent intervention of her LE, which was complex, and it was successful. The intervention was done under intravenous (IV) sedation, not general anesthesia. After the procedure, her condition was stable.
Because of incomplete revascularization and non-healing ulcer on her foot, vascular surgery consultation was requested. A computed tomography (CT) of the abdomen and pelvis was done. Because the patient was stable, underwent non-urgent revascularization in elective manner, and the procedure was uneventful, the inpatient level of care was not medically necessary. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	Coronary Artery Occlusion	

Treatment: Cardiac Catheterization

The insurer denied inpatient stay.  The denial is upheld.

Adult male with a history of hypertension, pulmonary sarcoidosis, and substance abuse presented to the hospital for cardiac catheterization following a positive stress test.  Prior to stress testing, the patient reported symptoms of worsening dyspnea on exertion.  Cardiac catheterization revealed 70-80% (percent) proximal right coronary artery (RCA) obstruction. Left ventricular ejection fraction was 60%.  A drug eluting stent was placed in the RCA.  No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization.  He underwent an uncomplicated procedure, and a stent was placed in the proximal right coronary artery. He was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference 1-4)

Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. (Reference 4)

The patient could have been managed at a lower level of care. The medical necessity for inpatient admission is not substantiated.

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain	
Treatment: Inpatient Treatment

The insurer denied hospital admission. The denial is upheld.

The patient has a past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, alcohol dependence, pheochromocytoma, and recent adrenalectomy and presented to the emergency department with complaints of right lower abdominal pain and lower extremity erythema and swelling.

Vitals on presentation included: Temperature (T) 96.9 (degrees) Fahrenheit (F), blood pressure (BP) 121/82, pulse (P) 78, respiratory rate (RR) 18, oxygen (O2) saturation 96% on room air (RA). Laboratory results included the following: white blood cell (WBC) 8.8, hemoglobin (HGB) 10.1, hematocrit (HCT) 30.7, creatinine 1.1, and glucose 117.

The patient's admission to the hospital was for a possible wound infection/cellulitis and pain management. The patient received intravenous antibiotics (Ancef). The patient reported their pain was much better controlled and that "they did not pick up their pain medication before checking into their drug treatment facility and received no medications after they left the hospital." The patient remained afebrile and hemodynamically stable. The patient was discharged to drug rehabilitation. 

According to documentation, the patient was admitted to the hospital for possible cellulitis and pain management. Otherwise, the patient was afebrile and hemodynamically stable, with unremarkable laboratory results, including a normal WBC. The patient had no evidence of a disseminated infection and required no surgical intervention. Based on the above findings, the patient met the observation level of management criteria. The patient did not meet the criteria for acute hospitalization.

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

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a male with a medical history of hypertension, obesity, and hemorrhoidectomy. He presented to the emergency department with lower abdominal pain, watery diarrhea, and dark rectal bleeding, starting after a colonoscopy with polypectomy two weeks prior, and then subsequent hemorrhoidectomy. A computed tomography scan of the abdomen and pelvis showed generalized moderate to severe circumferential mural thickening of the ascending colon and rectum suspicious for underlying pancolitis with differential diagnosis including pseudomembranous colitis, a small umbilical hernia containing a small amount of fat with mild fat stranding for which underlying inflammatory change cannot be excluded, and a 4 millimeter (mm) right hepatic lobe hypoattenuating lesion too small to characterize. He was treated with intravenous fluids, ondansetron, famotidine, pantoprazole, ciprofloxacin, and metronidazole. He was made nil per os (nothing by mouth). A gastroenterology consultation noted acute colitis, most likely infectious colitis; the recommendation was to obtain stool studies for gastrointestinal pathogens, and empiric antibiotic therapy. He had an improvement in the diarrhea and bleeding, no abdominal pain, and felt better. Lab results showed an unremarkable complete blood count and basic metabolic panel. Stool pathogen panel was positive for Campylobacter. He was discharged. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not medically necessary, and the care provided could have been provided at a lower level of care. The patient presented with abdominal pain, diarrhea, rectal bleeding, and imaging showing colitis. He was appropriately treated with antibiotics for Campylobacter infection [1-4]. However, he 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, empiric antibiotics, and gradual advancement of diet, and she had rapid improvement in symptoms [1-3]. No other gastrointestinal cause for the inpatient level of care, such as inflammatory bowel disease flare, peritonitis, abscess, fistula, or other complication was documented [4-7]. The care provided, including monitoring, labs, imaging, Gastroenterology consultation, and antibiotic therapy, could have been performed in sequence after presentation and without the need for the inpatient level of care. [1-5]. For these reasons, the inpatient level of care is not supported.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female who presented to the hospital emergency department (ED) with upper abdominal pain and vomiting. She had been seen twice in the ED previously for epigastric pain and vomiting. At the time of presentation, the patient was without a fever and her vital signs were normal. She was tender diffusely in the abdomen. The white blood cell count (WBC) count was normal at 9.6 thousand (K). The complete metabolic panel identified normal liver enzymes and bilirubin. She had previously been evaluated with a computed tomography (CT) scan and abdominal ultrasound. The CT reportedly showed mild colonic wall thickening. The ultrasound reportedly showed gallbladder wall thickening and sludge. She was admitted to the hospital.
Surgery and gastroenterology consultations were requested. Gynecology consultation was requested. No acute gynecology intervention was proposed. Upper endoscopy was performed showing mild gastritis. The patient reported improvement in abdominal pain and vomiting. A hepatobiliary iminodiacetic acid (HIDA) scan was performed and reported biliary dyskinesia. The patient underwent laparoscopic cholecystectomy. The operation was performed without complication. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged.
At issue is the medical necessity of an inpatient stay.
An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with recurrent abdominal pain and vomiting. She had been seen in the ED on several occasions previously for similar abdominal complaints. During this presentation, she was evaluated by gastroenterology, gynecology and surgery. She was determined to have biliary dyskinesia/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. Progress notes state that her abdominal pain and vomiting had improved. The gastroenterology and gynecology assessments did not identify any acute pathology that required inpatient admission. She underwent surgery to remove the gallbladder. The patient responded favorably to treatment and was stable for discharge from the hospital following surgery with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, clinical evaluation, monitoring, laparoscopic cholecystectomy, provision of intravenous (IV) antiemetics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left sided weakness, facial numbness.

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


This is an adult who presented to the emergency room (ER) for the evaluation of left sided weakness and who stated he was having imbalance while walking and had some numbness to the left side of the face. His spouse noticed slurred speech. On exam, the patient was noted to have a left sided facial droop and paresthesia. He also reported that he fell prior to presentation. On exam, the patient was noted to be positive for weakness.

An X-ray of the chest was done and showed left upper lung 1.3 centimeter (cm) nonspecific opacity, computed tomography (CT) of the chest showed no suspicious lesional pathology identified, finding on chest radiograph likely projectional, there was a mild centrilobular emphysema seen. A (CT) of the carotids showed grossly unremarkable angioarchitecture, no severe flow-limiting cerebral vasculopathy seen.  Magnetic resonance imaging (MRI) of the brain revealed acute infarct in the posterior limb of the right internal capsule measuring 1.3 x 0.4 cm and a small old right eternal capsule, corona radiata and left basal ganglia lacunar infarcts. An electrocardiogram (ECG) revealed normal sinus rhythm (NSR).

The patient was given sodium chloride 0.9 percent (%) intravenous (IV), famotidine 20 mg IV, metoprolol oral (PO), amlodipine PO, aspirin PO, and clopidogrel PO. 

He was admitted with a National Institute of Health Stroke Scale (NIHSS) Score of 4 with left foot weakness and left facial numbness and was placed on neurological assessments and fall precautions. Neurology consult was done, and he was noted with left sided mild appendicular ataxia, left sided sensory loss. The patient left against medical advice (AMA).
 
According to the Milliman Care Guidelines (MCG), hospital admission is needed for appropriate care of the patient. Based on the review of the medical records received, the patient meets the criteria due to his left-sided weakness for 2 days, left arm weakness, slight left facial droop, slurred speech, and feeling off balance, and a National Institute of Health Stroke Scale (NIHSS) Score of 4. In addition, magnetic resonance imaging (MRI) of the brain revealed acute infarct in the posterior limb of the right internal capsule and a small old right eternal capsule, corona radiata and left basal ganglia lacunar infarcts. 

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

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

The patient is a female without significant past medical history who presented with abdominal and back pain. She reports the pain was sudden onset, right sided, 10/10 in intensity and radiating to the groin. The pain was associated with nausea and one episode of emesis. She denied dysuria, frequency or urgency. She was afebrile with a heart rate of 94, a blood pressure of 140/83, a respiratory rate of 17 and she was not hypoxic. On exam, she had positive costovertebral angle tenderness. Her labs showed a white blood cell count (WBC) of 10.1, a hemoglobin of 11.0, and a creatinine of 0.96. A chest x-ray was unremarkable. A computed tomography (CT) of the abdomen and pelvis revealed mild right hydronephrosis and hydroureter, mild to moderate inflammation surrounding the right kidney and ureter suggestive of acute pyelonephritis, a 1.7 centimeter (cm) indeterminate cortical lesion in the left kidney, constipation, small fat containing umbilical hernia. His urinalysis was not consistent with a urinary tract infection. 

The inpatient admission was not medically necessary.

The patient presented with abdominal pain and back pain. She was diagnosed with probable acute pyelonephritis. She was hemodynamically stable. She did not have respiratory distress or hypoxia. She did not have severe pain, nausea or vomiting that requiring inpatient management. She did not have acute kidney injury. She did not have bilateral ureteral obstruction or unilateral obstruction of a solitary kidney. She did not have a renal abscess, emphysematous pyelonephritis or concern for infected foreign body. She did not have a documented immunosuppressed state. She did not have documented bacteremia. She did not have a history of failed outpatient management. She did not have a documented multi-drug resistant organism that would require prolonged IV antibiotic therapy. She did not have a documented reason as to why she could not receive oral antibiotics. She could have been safely and appropriately managed at a lower level of care with subsequent outpatient follow up.