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

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

The patient is a man who presented to the emergency department (ED) with a history of progressively worsening abdominal pain of one day duration. Past medical history was significant for human immunodeficiency virus (HIV). His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was 70/minute. Lab data identified a white blood cell (WBC) count of 17.5 K. A CT scan yielded the diagnosis of acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.

An Acute inpatient admission was not medically necessary for this patient.
This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, IV antibiotics and an appendectomy. The early post-surgical course was uncomplicated and the patient was clinically stable. He was stable for discharge from the hospital.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The patient tolerated oral hydration, diet and medication. Pain was well controlled.

The care and treatment provided could have appropriately been rendered at a lower level of care. The patient was clinically stable at the time of presentation and remained so during the course of care. This lower level of care would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylaxis.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a boy with a history of a nut allergy, who presented to the emergency department with anaphylaxis.

He has a known allergy to nuts and was well until the afternoon of presentation when he ingested chocolate with nuts.  He immediately developed difficulty speaking, dysphagia, erythema, and pruritus.  He also vomited.  He took epinephrine at home and called emergency medical services. The emergency medical services team administered epinephrine, Solu-Medrol, Benadryl, and Zofran.  He improved, but while waiting in the emergency department he experienced another episode of throat swelling and flushing.  He received another dose of epinephrine at that time, as well as a second dose of Solu-Medrol. He was subsequently admitted for further care for anaphylaxis.

The Inpatient Hospital Admission was medically necessary for this patient.

Risk factors for biphasic anaphylactic reactions include a severe initial presentation or the need for more than one dose of epinephrine.  This patient required 3 doses of epinephrine and 2 doses of Solu-Medrol, raising his risk for recurrent symptoms.  An inpatient admission for these patients is indicated to allow for prompt treatment in the case of a biphasic response.

This is a teen boy who presented with significant anaphylaxis requiring extensive treatment both from emergency medical services while in route and in the emergency department.  He received 3 doses of epinephrine, as well as 2 doses of Solu-Medrol, due to persistent and severe symptoms of anaphylaxis.  He therefore required inpatient admission for ongoing treatment for anaphylaxis, monitoring for potential biphasic reaction, and electrolyte monitoring.

The decision-making at the time of admission for this patient was consistent with his young age, the presence of severe anaphylaxis requiring intensive therapy, and the concern for ongoing symptoms with a potential second phase requiring additional prompt treatment in an inpatient setting to prevent potentially serious morbidity.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a man who was escorted to the emergency department (ED) by a cardiac electrophysiologist after presenting with complaints of tachycardia and lightheadedness. An electrocardiogram showed monomorphic ventricular tachycardia at a rate of 174 beats/minute. His medical history was remarkable for nonischemic cardiomyopathy, heart failure with reduced ejection fraction (25-30%), diabetes, hypertension and hyperlipidemia. 

Based on the information provided, an inpatient hospital admission was medically necessary.

This patient, with a nonischemic cardiomyopathy and severe left ventricular systolic dysfunction, presented with sustained monomorphic ventricular tachycardia (VT). The arrhythmia had not been terminated by his implantable cardioverter defibrillator (ICD). The medical record provided does not specify the reason for this. However; per the appeal letter, it was due to device malfunction. Sustained VT is a life-threatening arrhythmia. Thus, in the face of a malfunctioning ICD, this patient required careful and continuous monitoring with the ability to intervene emergently should his arrhythmia recur. This required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The health plan's determination is overturned.

The patient is a female who presented to the hospital for scheduled cardiac catheterization for evaluation of one month of exertional dyspnea and lightheadedness. Her medical history was remarkable for orthotopic heart transplantation for nonischemic cardiomyopathy; coronary artery disease in the transplanted heart with multiple percutaneous coronary interventions, and human immunodeficiency virus (HIV) infection. Upon presentation she was hemodynamically stable, without ischemic electrocardiographic changes. Her serum troponin I level was less than .01 nanograms/milliliter (ng/ml). Coronary angiography showed an 80-90%(percent) in-stent restenosis in the proximal left circumflex artery and a 70-80% lesion in the distal vessel. The vessel was heavily calcified. The proximal lesion was treated with rotational atherectomy; a drug-eluting stent was placed in the distal vessel. The patient was admitted to the hospital post-procedure. Her troponin I level rose to 1.32 ng/ml. Her level was 6.21 ng/ml. An echocardiogram showed a left ventricular ejection fraction of 55%; there was inferior, apical and septal hypokinesis that was worse compared to prior studies. An electrocardiogram showed no acute changes. The patient's troponin I level was 4.09 ng/ml. She was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is overturned.

This patient presented for elective coronary angiography. Her left circumflex artery was heavily calcified and required rotational atherectomy to treat a lesion in the proximal vessel and a drug-eluting stent for a more distal stenosis. Her serum troponin level, which had been normal upon presentation, rose more than 100-fold and continued to rise over the next day. An echocardiogram showed new wall motion abnormalities. This patient met diagnostic criteria for a type 4a myocardial infarction. In patient's undergoing percutaneous coronary intervention who have normal baseline troponin levels, more than a five-fold increase in the post-procedure level has been associated with an increase in the risk for short and long term major adverse cardiac events. Given the patient's risk for post-procedure complications, she required careful and continuous monitoring with the ability to intervene emergently, if needed. This required an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a male with a past medical history significant for anxiety, hyperlipidemia, and psychological disorder who presented with complaints of chest pain. The chest pain started one day before the presentation. It was described as cramping, intermittent. He denied associated symptoms including dyspnea, nausea, diaphoresis, palpitations, dizziness, or lightheadedness. By the time the patient was seen by the admitting physician, the chest pain resolved. The patient had no other complaints. He was started on a heparin drip. In the hospital, the patient was seen by a cardiologist. According to the consultation note, the patient had negative cardiac markers and unremarkable electrocardiogram (EKG). It was mentioned that a coronary computed tomography (CT) angiogram was attempted, however, the computed tomography angiography (CTA) portion was deferred secondary to an elevated calcium score. Subsequently, the patient was transferred for cardiac catheterization. 
The cardiac catheterization revealed that the patient had a normal left ventricular ejection fraction. There was severe mid circumflex (LCx) stenosis. The patient underwent successful percutaneous coronary intervention (PCI) of the mid-LCx. The patient had occluded proximal right coronary artery (RCA). During the hospital stay, the patient remained in stable clinical condition. He was discharged home with a recommendation to follow up with cardiology service in order to have staged PCI as an outpatient. 

The requested health service/treatment of inpatient stay was necessary for this patient. 
The patient presented with symptoms suggestive of unstable angina and was appropriately started on a heparin drip. The patient required a rule-out of the acute coronary syndrome and an angiogram with PCI. Based on the clinical symptoms and results of cardiac catheterization, this patient had unstable angina in the setting of significant coronary artery disease. 
Based on the current standards of care, the severity of the patient's condition and the complexity of the services provided completely justified the acute inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal Obstruction.
Treatment: absorbable nasal implants-Latera implant.
The insurer denied absorbable nasal implants-Latera implant.
The determination is overturned.

The patient has a long-standing history of nasal airway obstruction. She had a prior septoplasty and bilateral endoscopic sinus surgery which did not resolve her symptoms. She was seen by her provider. The symptoms also did not improve with steroid nasal spray. At that time, she reported nasal obstruction and mid facial pressure which improved with Breathe-Rite strips. The physical examination showed bilateral nasal valve collapse which improved with a modified Cottle maneuver. The patient underwent a turbinate reduction and Latera implant and reported significant improvement in her symptoms.
At issue is whether the absorbable nasal implants- Latera implant are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Latera implants are likely to be more beneficial than any standard treatment for this patient's condition.
The patient has a documented nasal valve collapse based on the provider's note which improved with the modified Cottle maneuver. This patient had already failed to improve with a prior septoplasty and functional endoscopic sinus surgery. She also failed to improve with appropriate medical therapy (nasal steroid spray and antihistamine).
The standard procedure at this point would be an open functional septorhinoplasty with batten or spreader grafts made from harvested cartilage. This has a success rate of 80-90% percent which is roughly equivalent to the Latera implant and this has been shown in studies (1).
However, an open septorhinoplasty is a significantly more invasive surgery with a higher complication rate which requires a much longer recovery time. When considering the invasiveness and recovery time, the Latera implant is more beneficial than the standard treatment of open functional rhinoplasty.
Multiple studies have shown the Latera implant to be an effective and durable (at least 2 years of symptoms relief) treatment for nasal valve collapse (2).
 
This patient already had the procedure and has reported in her appeal letter significant symptom relief. Multiple studies have shown this to be an effective, durable and less invasive treatment for nasal valve collapse.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal Obstruction.
Treatment: absorbable nasal implants-Latera implant.
The insurer denied absorbable nasal implants-Latera implant.
The determination is overturned.

The patient has a history of a deviated nasal septum, and inferior turbinate hypertrophy. She is status postnasal septum reconstruction. However, following the surgery the patient had continued nasal congestion and internal nasal valve collapse. The symptoms appeared to improve about 40% using a Breathe-Rite strip. The patient underwent turbinate reduction and Latera implant which relieved the nasal congestion symptoms.
The Latera implant was used because of the physical findings and history of the nasal valve collapse. At issue is whether absorbable nasal implants- Latera implant are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The patient has a prior history of nasal congestion that was not completely improved with septoplasty. A modified Cottle maneuver confirmed the presence of internal nasal valve collapse (along with improved symptoms with Breathe-Rite strips). Following the procedure, the congestion symptoms improved the valve collapse. As the patient had a prior nasal surgery involving the septum, the Latera implant prevented the patient from undergoing a more invasive open nasal surgery to correct the nasal valve collapse. The Latera procedure was likely to be more beneficial than the open nasal surgery.
The current literature, Brandon et al 2020, has shown efficacy of the Latera implant to improve nasal valve collapse. There are no current national guidelines on the use of absorbable implants. However, the American Academy of Otolaryngology Head and Neck Surgery has opined on the use of the appropriate CPT code(Current Procedural Terminology) for the use of the device (therefore suggesting that the device can be used in the appropriate setting).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal Obstruction.
Treatment: absorbable nasal implants-Latera implant.
The insurer denied absorbable nasal implants-Latera implant.
The determination is upheld.

The patient has a nasal obstruction. Medical management has included nasal steroids, saline rinses, Singulair and oral anithistamine. An exam revealed nasal valve collapse. Previous treatment has included septoplasty. At issue is whether the absorbable nasal implants-Latera implant are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The requested Latera implant in not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There are a lack of well designed, unbiased, long-term studies demonstrating that the Latera implant is equivocal or superior when compared to standard rhinoplasty techniques. Current studies are heterogenous and do not have long term results.
Although there is a growing body of literature regarding this implant, it has not been shown to be as effective or superior to standard nasal valve surgery. A recent meta-analysis by Kim et al. concluded that bioabsorbable nasal implants may reduce nasal wall movement and subjective symptom scores compared to preoperative status. More randomized clinical trials must be conducted to further verify the effectiveness of bioabsorbable nasal implants. Latera implant is not yet considered standard of care for treatment of external nasal valve collapse. More well-designed studies are needed to determine its long term safety and efficacy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety

Treatment: Psychiatric inpatient hospitalization

The insurer denied coverage for psychiatric inpatient hospitalization

The denial is upheld 

This patient is a male who reportedly was admitted to this psychiatric hospital due to psychotic symptoms as an involuntary admission. He reportedly had paranoid delusional thinking, auditory hallucinations, bizarre behavior including laughing to self, locking self in the bathroom, confusion and disorganization, agitation, internal preoccupation, fearfulness and anxiety, and he was not answering questions. His diagnosis was Psychotic Disorder. He also had reported developmental delays and a diagnosis of autism spectrum disorder and Profound Intellectual Disability. He reportedly took Risperidone and Depakote and improved to his baseline. He reportedly was discharged to a group home.
  
The medical records did not provide enough specific evidence to support that he only required 24-hour inpatient hospital treatment then. The MCG (Milliman Care Guidelines) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible to meet criteria for inpatient behavioral health level of care. In this case it was reported that he no longer had bizarre behavior, hallucinations, delusional thinking, and he was cooperative and compliant and at his baseline. It was reported that he remained until he was able to be discharged to a group home instead of going to his parent's home first and then the group home. It was reported that he had lived with his parents prior to this hospitalization. Notes reported that he had no paranoia or delusions, was in good behavioral control, cooperative, denied hallucinations, had normal speech and psychomotor activity, linear thought process, and denied suicidal or homicidal ideation. There was no specific evidence that he still had severe or moderate psychiatric symptoms or that he could not safely be discharged home until a bed became available. Also, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute hospital setting then or that could not be achieved in a less restrictive level of care then.  As a result, the recommendation is to uphold the previous decision and deny coverage for continued inpatient mental health treatment in this hospital. 

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

The insurer's denial of coverage for psychiatric inpatient hospitalization is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

This case describes a male patient with a complaint of left leg pain and deformity. He sustained a left leg injury as a teenager and had persistent pain in the left knee and leg due to a rotational deformity. An elective femoral osteotomy and intra-medullary nail placement was performed to correct this. The surgery was successful with no documented complications. The patient was admitted to the hospital overnight and had an issue with urinary retention that required catheterization. This eventually resolved and the patient was discharged home. At issue in this case is the medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. The records document that this patient suffered from a chronic left leg deformity from a femoral shaft fracture he sustained as a teenager. He had persistent leg pain and limitation of his function secondary to this condition. He opted to undergo elective left femoral derotational osteotomy surgery. This surgery was completed successfully with no documented complications. The care rendered was consistent with the current standard of care with regard to femoral rotational deformity as documented by Hatem and colleagues in the Arthroscopy journal in 2021 and by Buly and associates in the Journal of the American Academy of Orthopedic Surgeons in 2018.
The provided documentation in the records, however, does not support the inpatient hospital admission. The patient had no documented complications. There was no documentation of excessive bleeding and there was no documented signs of infection of blood clots following the operation. The patient's vital signs and lab values were within normal limits after surgery as well. The progress note stated that the patient had some urinary retention that had resolved with catheterization and that he was using Flomax as an oral medication to aid with this. In addition, his pain was controlled with oral medication, and he participated in physical therapy with 50% (percent) weight bearing on the left leg. Thus, based upon the documentation in the patient's medical records, the inpatient stay was not medically necessary. The patient could have been managed at a lower level of care status.