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

Mental Health: Inpatient

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

The patient is a male with diagnoses of Generalized Anxiety Disorder (GAD), Panic Disorder (PD) and Major Depressive Disorder (MDD). He developed suicidal ideation as well as some thoughts of harm to others. His outpatient physician ordered him to the emergency room for evaluation after outpatient treatment was found to be ineffective. In his current illness, he did show severe functional impairment with decreased effectiveness at work and stopped work, which worsened his self-esteem.

The inpatient mental health treatment was medically necessary for the patient. First, this patient had a pattern of relapsing from an early morning euthymic state to a state of being anxious later in the day and worried about whether he should be discharged. It would be against good medical judgment to discharge the patient. He would have a high risk of requiring re-hospitalization or self-harm. Second, his illness was chronic and had worsened considerably since his effective past treatment, with new development of severe neurovegetative symptoms. Thirdly, his MDD was comorbid with his GAD and PD. As a result, a combined treatment was required and a closer observation for improvement in both his MDD and GAD/PD was required throughout the day. Paying attention to only the mood component in one part of the day would represent only partial treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylactic Allergic Reaction

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned.    

This is a male patient with a history of multiple food allergies, prior anaphylaxis, atopic dermatitis and eosinophilic esophagitis. The patient was brought to the hospital on for an allergic reaction after accidental milk ingestion. The patient was treated with epinephrine at home and in the field (by EMS) prior to arrival to the hospital. In the Emergency Department (ED), the patient was noted to have wheezing, urticaria, tachypnea, prolonged capillary refill that prompted the need for 2 more doses of epinephrine treatment. Because of recurrent urticaria and wheezing even after initial hospital administered epinephrine treatment, the patient was admitted to the Pediatric Intensive Care Unit (PICU). The patient was treated with steroids, intravenous (IV) fluids, antihistamines/H2-blockers and bronchodilators. The patient was monitored overnight and was discharged the following next day. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient had a prolonged anaphylactic reaction that was consistent with biphasic anaphylaxis. According to literature, biphasic anaphylaxis and ingestant allergen exposure are considered risk factors for severe anaphylaxis for a longer period. The fact that this patient required multiple epinephrine doses and was present with wheezing are also considered risk factors for severe anaphylaxis. It was thus reasonable to admit the patient who presented with several characteristics of severe anaphylaxis, to the hospital for close monitoring and treatment. The patient's acute and severe clinical presentation could not have been safely treated at a less intensive level of care than inpatient admission.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for inpatient hospital services is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease/viral infection
Treatment: Inpatient stay
The insurer denied the inpatient hospital stay as not medically necessary
The denial is upheld in whole

This case involves a patient with invasive ductal cell carcinoma status post lumpectomy and radical lymph node dissection, with subsequent bilateral mastectomy, who presented to the hospital with fevers, myalgias, nausea vomiting, and nonproductive cough. Symptoms have been present for several days, slightly relieved with Tylenol. At the time of the fever, the patient was undergoing radiation treatment and missed radiation treatment by coming into the emergency department to be evaluated. The patient is also currently on immunotherapy every three weeks, with the last treatment 30 days before presentation. The patient reported a fever of 102.5 and denied any sick contacts-no dysuria, nausea, vomiting, diarrhea, or constipation. On exam, the patient is noted to have no acute distress. The cardiopulmonary exam is relatively unremarkable, including no wheezes or rhonchi on the lung exam-the medical team documents erythema of the right chest wall, but no cervical lymphadenopathy. Laboratory studies were done, showing a white blood cell count of 2.6, with 12% bandemia and hemoglobin of 10. The lactate was 1.7. The rest of the chemistry panel was unremarkable. Influenza swab was performed, and it was positive for influenza B. The patient was admitted to the hospital, started on intravenous (IV) fluids and Tamiflu and was placed on droplet precautions. Oncology was consulted. They suspected the white blood cell count suppression, is a combination of marrow suppression from viral infection and decreased marrow reserve from previous chemotherapy. Overall the patient was feeling symptomatically improved and did have a bout of nausea and some diarrhea, along with a headache. The following day, the patient reported an overall improvement in influenza symptoms and was discharged. 

The requested health service/treatment of inpatient stay is not medically necessary for this patient.
The patient has no evidence of hemodynamic instability, no evidence of bacteremia, or hypoxemia. The vital signs, and the laboratory work-up, are not indicative of sepsis. There is no failure of outpatient treatment. The patient gained the ability to tolerate food and water within 48 hours of hospitalization and was deemed stable for discharge. The fever did not exceed 104 F. There is no end-organ dysfunction related to the influenza infection. It is the standard of care per most hospital protocols, to isolate patients with influenza in the hospital, and is not indicative of strict isolation based on the patient's specific condition. Typically patients with an absolute neutrophil count of less than 500 are considered to be severely neutropenic and require specific isolation for neutropenic precautions. The patient was appropriately observed in the hospital, for up to 48 hours, given the presence of underlying malignancy. However, the acuity of the hospitalization did not satisfy clinical indications for inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain with darkening stools
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who had presented to the facility in question with a report of two days of worsening abdominal pain with increasingly darkening stools. There was no non-steroidal anti-inflammatory drug (NSAID) use, tobacco or alcohol use. There was no hematemesis, nausea, emesis, dizziness, shortness of breath or fevers or chills.  The patient had a history of a prior gastrointestinal (GI) bleeding with a duodenal ulceration. The patient was recently started on Xarelto. The patient had initially presented to his private physician with melena and hypotension with a systolic blood pressure in the 80s. The Xarelto was held. The presenting systolic blood pressure was 104. The presenting hemoglobin was 11.1. An esophagogastroduodenoscopy (EGD) showed a non-bleeding duodenal ulcer. The patient was noted to be clinically stable on presentation and the patient received supportive care with a discharge when deemed improved. 

No, as explained in detail below, the proposed inpatient admission was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an upper GI bleeding event, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring, need for a blood transfusion, severe electrolyte dyscrasias or any other indication for an acute admission. An endoscopy can be performed as an observation level patient or an outpatient.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory distress, Asthma, Upper respiratory infection. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is male child with a history of asthma, obesity, and autism. The patient had a history of 5 Emergency Room (ER) visits for asthma in the past year and a frequent nocturnal cough. The patient was not taking any daily anti-inflammatory therapy for asthma. The patient had been sick with an upper respiratory infection (URI) for 4 days and began coughing 3 days prior to this admission. The patient's mother treated the patient with albuterol on several occasions and when the patient was noted to have difficulty breathing, the patient's mother brought him to City MD for an evaluation. City MD contacted emergency medical services (EMS) to request that the patient be transferred immediately to the ER for treatment. In the ambulance, the patient was treated with oxygen and a dose of inhaled Duoneb; the patient was noted to have hypoxemia at 86%. In the ER, the patient was noted to have tachycardia and shortness of breath with inspiratory and expiratory wheezing. The patient was also treated with inhaled Duoneb on three occasions, Solu-medrol, intravenous (IV) magnesium and a bolus of IV normal saline. A venous blood gas was significant for an elevated pCO2 of 41 which was concerning for risk of respiratory failure in a tachypneic patient with asthma. When the patient did not improve with treatment in the ER, the decision was made to admit the patient to the hospital for an acute episode of asthma for ongoing treatment with albuterol every 2 hours. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient was treated appropriately in the ER for status asthmaticus. The patient's history was significant for frequent ER visits in the past for asthma and the patient was not taking any preventive asthma therapy at home. The patient continued to have tachypnea with retractions and required ongoing albuterol inhalation treatments every 2 hours which could not have been safely provided at home. The decision to admit the patient to the hospital for ongoing treatment was appropriate and consistent with the standard of care for status asthmaticus. As per UpTodate, hospitalization is warranted for a child of any age whose family cannot provide appropriate care and assure compliance with the management plan. Additional indications for hospitalization includes hypoxemia (oxygen saturation <90% in room air) and moderate to severe respiratory distress (i.e. respiratory rate >50 breaths, retractions, nasal flaring, difficulty breathing, apnea, grunting), which apply to this case. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal canal stenosis and cervical myelopathy
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is male. He presented to the emergency room with a recent history of worsening right lower extremity weakness. He had two recent falls. He states burning central back pain since the day before. Medical records noted recent diagnosis (three days prior) of disc bulging at C5-6, causing cord compression; he left the hospital AMA (against medical advice). The patient was seen and evaluated by neurosurgery service; Neurosurgery attending noted that the patient has a history of a middle cerebral artery and lower back pain for several years and ambulates with a rolling walker. The examination was notable for brisk reflexes on the right, antalgic gait with the right leg and limping, decreased right lower extremity strength, and decreased right lower extremity range of motion. It was noted that the patient has paraspinal muscle tenderness, but normal
motor strength (right hip flexion of 4/5, antalgic), normal reflexes, and normal sensation. Provider's impression was cervical encephalomalacia, suspected to be chronic without acute transverse myelitis, congenitally narrow spinal canal, and chronic low back pain.

Follow up neurosurgical evaluation noted that there was no acute surgical intervention necessary. Pain management was recommended. The patient was also treated with IV Solu-Medrol. His lower extremity strength improved. He was discharged and asked to follow up outpatient. 

No, the Inpatient admission was not medically necessary.

The patient was admitted to the hospital for complaints of low back pain and right
lower extremity weakness. There was a concern for cord compression. He was
evaluated by neurosurgery service; Neurosurgery attending noted history of chronic
lower back pain for several years; patient ambulates with a rolling walker.
The provider's impression was cervical encephalomalacia, which was suspected to be
chronic. There was no evidence of acute transverse myelitis. Neurosurgery
concluded that no acute surgical intervention was necessary.
A review of hospital records does not support cauda equina syndrome. Hospital
management/treatment was conservative, without any surgical intervention.
Furthermore, the patient was hemodynamically stable on admission; there was no
evidence of sepsis, change in mental status, acute respiratory failure, active
hemorrhage that required a blood transfusion, cardiac arrhythmia, severe heart
failure, acute renal failure, and severe electrolyte abnormalities.
The proposed treatment is not medically necessary because the care rendered
could have been performed at a lower level of care without adversely affecting the
patient's health.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic sinusitis, Deviated nasal septum, Pathologic obstructive right concha bullosa, Bilateral hypertrophic inferior turbinates, Internal nasal valve vestibular stenosis
Treatment: Endoscopic Sinus Surgery
The insurer denied coverage for Endoscopic Sinus Surgery.
The denial is overturned.

This is a male patient who was initially referred for evaluation of a very complex history of nasal obstruction, deviated septum, obstructive sleep apnea and chronic rhinosinusitis. The patient had a long history of sinus issues and deviated septum from unrecognized nasal trauma. Subsequent to the above, the patient developed progressive nasal obstruction, progression of sinonasal disease, and post-obstructive sinus pathology with recurrent chronic sinusitis.  He presented initially with severe facial pain as well as sinus pain, pressure, headache, and nasal blockage. He had an altered sense of smell that had worsened over 2 years in the setting of recurrent sinus infections. He was typically treated with antibiotics and the infections would respond in the past; however, his condition had greatly worsened with his chronic sinus infection was not responding to a number of antibiotics.  

He cannot tolerate Allegra and Claritin due to sedating effects that worsens his sleep apnea. He has also failed nasal steroid sprays and saline irrigations. The patient had reached a point where sinonasal condition was not responsive to conservative management and the facial pain and pressure, as well as postnasal drainage and obstruction, were affecting his quality of life and ability to function. Therefore, the patient underwent evaluation with sinonasal endoscopy confirming left severe nasal septal deviation.  A computed tomography (CT) scan confirmed nasal airway compromise and obstruction with severe nasal airway narrowing.  The patient underwent surgical intervention that included endoscopic resection of pathologic right obstructive concha bullosa, septoplasty, endoscopic resection of bilateral inferior turbinates, and open endonasal repair of vestibular stenosis with bilateral spreader grafts and suture suspension. He also underwent CT navigational image guidance for approach to anterior skull base for functional endoscopic sinus surgery with bilateral maxillary antrostomy, bilateral anterior ethmoidectomy and bilateral frontal recess resection.

There is overwhelming scientific evidence in peer-reviewed literature indicating that endoscopic sinus surgery to establish patency of the sinus outflow tracts is beneficial to patients with chronic rhinosinusitis. This patient was a good candidate for endoscopic sinus surgery since maximal medical therapy had not alleviated his chronic rhinosinusitis.  

Based on the patient's anatomy, failure of medical therapy, persistence of disease on CT scan and examination, the requested service is likely to be more beneficial than any other standard treatment/procedure for this patient.

The carrier's denial of coverage for Endoscopic Sinus Surgery should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic sinusitis, Deviated nasal septum, Pathologic obstructive right concha bullosa, Bilateral hypertrophic inferior turbinates, Internal nasal valve vestibular stenosis 
Treatment: Endoscopic Sinus Surgery
The insurer denied coverage for Endoscopic Sinus Surgery.
The denial is overturned.

This is a male patient with a history of diabetes mellitus (DM), sleep apnea, chronic sinusitis, deviated nasal septum, pathologic obstructive right concha bullosa, and bilateral hypertrophic inferior turbinate and internal nasal valve vestibular stenosis. The patient underwent computed tomography (CT) navigational image guidance, endoscopic resection of pathologic right obstructive concha bullosa, septoplasty, endoscopic resection of bilateral inferior turbinates, and open endonasal repair of vestibular stenosis. 

The patient had the following preoperative diagnosis: chronic sinusitis, deviated nasal septum, pathologic obstructive right concha bullosa, bilateral hypertrophic inferior turbinates, and internal nasal valve vestibular stenosis. Surgical path revealed: left sinus with sinonasal mucosa and minimal chronic inactive inflammation; and right sinus with minimum chronic inactive inflammation and fragments of septal bone and cartilage. Hamilos, DL in "Chronic rhinosinusitis: Management" in UpToDate 2020 noted the indications for surgical intervention include the following: failure of medical treatment, restoration of sinus ventilation (i.e., restoration of sinus ostial patency and removal of material from opacified sinuses), improvement of the penetration of topical medical therapies, and the debulking of severe polyposis, bony erosion or extension of disease beyond the sinus cavities. This patient meets the guidelines for surgical interventions as he has failed medical treatment. This procedure is an approved surgical procedure.

It appears that this patient was a good candidate for the surgery as listed, given the history, physical exam, sinus endoscopy, and CT exam. He had a chronic problem without improvement using conservative treatment.

The requested service is likely to be more beneficial given that standard medical treatments have not worked for this patient.  

The carrier's denial of coverage for Endoscopic Sinus Surgery should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza; Asthma; Chronic Obstructive Pulmonary Disease
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This female patient presented to the emergency department (ED) with complaints of shortness of breath (SOB), green phlegm, and wheezing. The patient has history of asthma, diabetes mellitus (DM), and hypertension (HTN). The patient had been seen by their primary medical doctor. She was diagnosed with bronchitis who prescribed some oral antibiotics. She had also taken her nebulizers at home, but her symptoms did not improve so she presented to ED.

Vital signs at presentation: Temperature (T) 98.7 F, Heart Rate (HR) 80, Respiratory Rate (RR) 20, Blood Pressure (BP) 108/67, oxygen (O2) saturations were 90% on room air. The patient was treated with nebulizers and Decadron by the emergency medical staff on the way to the hospital. The patient had a peak expiratory flow (PEF) around 210, but her baseline was not known. The patient was tachypneic with bilateral wheeze on lung exam. The patient was treated with bronchodilators, and oral steroids. The patient improved with treatment. As per the history and physical the patient was speaking in full sentences. There was no jugular venous distension (JVD); the lungs noted occasional wheezing. Cardiovascular system (CVS) was normal. The patient was alert and oriented. The neurological exam was non focal. White blood cell count (WBC) was 6.15 K Hb 11.2 g, electrolytes were within normal limits (WNL), BUN/Creatinine 13/0.9, BNP 84, Influenza A was positive. Chest x-rays revealed no acute infiltrate.

This patient did not need acute hospitalization. She responded to treatment in ED. The patient was afebrile, hemodynamically stable, had minimal wheeze on exam, and WBC was normal. The patient did not have oxygen saturations less than 90%; CXR was normal. The patient was not using accessory muscles. The patient was treated with bronchodilators, oral steroids, and Tamiflu.

This patient could have been placed on observation status. The patient improved with treatment. The patient was discharged on the day after admission and did not need acute hospitalization. The patient had mild asthma and responded to treatment in ED. The patient was stable to be discharged after a period in observation status. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.