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

Diagnosis: Uterine fibroids
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with a history of uterine fibroids. She was admitted to the hospital for an abdominal myomectomy.

The proposed inpatient hospital admission was not medically necessary.

The medical records and medical literature were thoroughly reviewed. There are no medical records submitted other than the preoperative consultation and associated records. Therefore there is no evidence in the medical records to confirm that the patient required acute inpatient admission, due to the lack of intraoperative and postoperative records. According to the preoperative medical records there are no significant co-morbidities in the patient to support postoperative acute inpatient admission. Therefore, the service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tragal inflammation
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

The patient is an adult female who presented with tragal inflammation. The patient has a medical history of diabetes, hypertension, and obstructive sleep apnea (OSA). About a month prior, a tragal piercing was performed. The patient had failed medical management via oral (PO) antibiotics for a tragal infection. An abscess was noted, and this was drained by the Ear, Nose & Throat (ENT) provider. Subsequently, the patient was noted to have concurrent hyperglycemia and the recommendation was made for admission in order to receive intravenous (IV) antibiotics for the ear infection and glucose management by Endocrinology. The glucose values were over 400. The A1C (glycated hemoblobin) was over 10. The request is to determine if the admission was medically necessary in the patient's case.

The patient presented due to failed medical management via PO antibiotics for a tragal infection. An abscess drainage was needed, and admission was deemed prudent because the glucose values were over 400 and IV antibiotics would benefit the ear infection. It was thought that the infection was severe due to uncontrolled diabetes and would recur without admission.  The severity of the infection and its refractoriness to oral antibiotics were thought to be due to the poorly controlled diabetes. The A1C was greater than 10 and the glucose greater than 400. The literature supports aggressive treatment of diabetics with poorly controlled glucoses. 

According to Cohen Atsmoni et al. (2019), "Therefore diabetes mellitus (DM) predisposes to certain infectious diseases, such as fungal sinusitis or malignant otitis externa, which are rare in general population."

According to Labib et al. (2022), "Such skin changes can offer insight into patients' glycemic control and may be the first sign of metabolic derangement in undiagnosed patients with diabetes. Recognition and management of these conditions is important in maximizing the quality of life and in avoiding serious adverse effects in patients with diabetes mellitus."

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient, as the requested services were medically necessary.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection (UTI).
Treatment: inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is overturned.

This case involves a toddler, who had no significant past medical history when they presented to the emergency room due to fever and vomiting.  They were transferred from another facility and diagnosed with a urinary tract infection.  The patient was given ceftriaxone and Zofran and tested positive for COVID (coronavirus).  Record stated that the patient began having fevers range between 102 degrees Fahrenheit (F) and 104 degrees F.  Initially, the patient's mother was more concerned, given that the patient had recently received vaccines.  The patient was treated for fever with 2.5 mL (milliliter) of Tylenol every 8 hours. Rectal temperatures were 102-104 degrees F daily.  The patient did well initially.  However, the patient was not tolerating oral intake, with fewer soiled diapers, with the patient described as "extremely tired" and difficult to arouse.  Urinalysis demonstrated evidence of UTI upon which the patient received 50 mg/kg (milligrams per kilograms) of ceftriaxone.  The patient had an elevated white blood cell count at 23 with electrolytes remarkable for bicarbonate of 14 and C-reactive protein elevated to 70.  The patient continued to not tolerate oral intake, despite Zofran, and was subsequently transferred for continued management of dehydration.  Nasal swab was positive for COVID.

According to the Milliman Care Guidelines, inpatient care is indicated for pediatric patients with UTI when they are hemodynamically unstable, which can include tachycardia, and when there is a need for intravenous hydration support despite observation care.  Inpatient care may also be indicated for pediatric patients who are unable to maintain oral hydration that persists after observation care and presents with vomiting that is severe or persistent.  In the case of this patient, given the young age, evidence of dehydration, tachycardia, multiple days of vomiting and fever despite conservative methods of treatment, as well as a diagnosis of both COVID and UTI, the inpatient care was appropriate for 2 days to ensure that the patient was receiving adequate hydration and medication to address multiple issues simultaneously and prevent more serious and rapid decline in health.  

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteotomy Maxilla and Osteotomy Mandible
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who underwent maxillary and mandibular osteotomies. The patient was seen for same day surgery and had uneventful surgical and anesthesia procedures. 
There were no untoward occurrences in the post-anesthesia care unit (PACU) and the patient was then transferred to a telemetry unit as an inpatient. The patient had a normal post-operative stay and was discharged the following evening.
An inpatient admission was denied based on lack of medical necessity.

The proposed inpatient hospital admission was not medically necessary.

While the orthognathic surgery procedures were medically appropriate, an inpatient setting was not medically necessary for these procedures.

Orthognathic surgery is routinely performed as an outpatient or observation procedure. Double jaw orthognathic surgery is routinely performed as an outpatient or observation procedure. A change to an inpatient admission would be necessary if there was excessive bleeding, an inability to take oral fluids or an airway concern. None of these were present for this patient. Therefore, the patient was an ideal candidate for a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolism. 
Treatment: Inpatient stay. 

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

The patient is a female who was admitted to the hospital for a pulmonary embolism. She has a history of a pulmonary embolism. In the emergency department (ED), the patient had left calf pain and there was an outpatient ultrasound that noted a deep vein thrombosis (DVT) after a recent flight. Labs noted a hemoglobin of 11.7. A computed tomography (CT) angiogram noted extensive bilateral pulmonary emboli without right heart strain. Vascular surgery was consulted and biomarkers were negative. Hematology was also consulted and recommended Eliquis. The patient's condition improved and she was stable at discharge on Eliquis. 

The patient in question does not meet medical necessity for the acute inpatient level of care per Milliman Care Guidelines (MCG) Criteria. In order to meet medical necessity, the patient must have hypoxemia, abnormal vitals, chronic cardiopulmonary disease, hemoptysis, arrhythmias, syncope, right ventricular dysfunction, or positive cardiac biomarkers. Additionally, according to Zondag et al., (2011) and Kearon (2003), the patient had both a deep vein thrombosis (DVT) and pulmonary embolism (PE) but there were no severe features which would need inpatient admission such as hypoxia or any other significant lab or imaging abnormalities. There were no other severe features or extenuating circumstances in this case. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Hospital Admission
The insurer denied: Hospital Admission
The denial is: Upheld

The patient is a male who presented to the hospital with a history of progressively worsening abdominal pain of 1-day duration. Past medical history included hypertension and asthma. Evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was 72/minute in the emergency department (ED). Lab data identified an elevated white blood cell (WBC) count of 14 thousand (K). CT scan yielded the diagnosis of appendicitis (thickened appendix with adjacent stranding). Treatment was initiated with intravenous (IV) fluid and antibiotics.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. He was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. He was discharged home.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. The care and treatment provided could have appropriately been rendered at a lower level of care status.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care designation would have provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.
Milliman Care Guidelines (MCG) criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed without inpatient admission. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case per the referenced criteria or generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bifrontal hemorrhagic contusion and occipital bone fracture
Treatment: Hospital Admission
The insurer denied: Hospital Admission
The denial is: Upheld

The patient is a female who was evaluated in the emergency room after she fell out of a golf cart. The patient struck her head and immediately developed a headache. She also developed nausea and vomiting. In the emergency room, the patient underwent numerous imaging studies. A computed tomography (CT) of the head showed bifrontal hemorrhagic contusions with some subarachnoid blood and an occipital bone fracture. A CT scan of the cervical spine showed no acute changes. The patient underwent a laceration repair of the scalp in the emergency room. The patient was admitted to the hospital for further care. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

An acute hospital admission was not medically necessary. The care provided was appropriate for a lower level of care status. The patient presented to the hospital for evaluation of a trauma. The patient had a head injury causing a scalp laceration that was repaired in the emergency room and a hemorrhagic contusion with some associated subarachnoid blood. These findings were initially discovered on imaging performed in the emergency room. Neurosurgery was consulted and there were no acute operative recommendations. The patient was observed for neurologic stability. There were no significant vital sign abnormalities or laboratory studies that required acute inpatient admission. The patient had no other comorbid conditions that required treatment at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting; Shortness of breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female with no significant past medical history. She presented to the ED (emergency department) complaining of vomiting and shortness of breath for 5 days. 
The patient was drinking alcohol and smoking marijuana five days previously and woke up the next day throwing up thinking it was a hangover. However, the patient had not been able to keep food down and had been vomiting several times per day. The patient had a loss of appetite. On exam, there was abdominal tenderness, RUQ (right upper quadrant). There was right CVA (costovertebral angle) tenderness and left CVA (costovertebral angle) tenderness.
The patient's labs were as follows:
Cannabinoid Screen, Urine: Positive
COVID-19: Detected
US (ultrasound) abdomen showed Cholelithiasis with 7 mm (millimeter) dilated common bile duct. 

The need to rule out common bile duct obstruction was noted. Negative sonographic Murphy sign was reported. It was noted that MRCP (Magnetic Resonance Cholangiopancreatogram) may be of value for further evaluation. The patient was treated with Ceftriaxone 2 grams IVPB (intravenous piggyback). She had 
improvement in the gastrointestinal symptoms. The COVID-19 infection was deemed to be asymptomatic.
The patient was discharged on day # (number) 2 with follow up with GI (gastroenterology) and surgery.

The Inpatient Hospital Admission was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. An observational level of stay would have been more appropriate for this patient. Observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing-by-mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous 
replacement, did not have PO (oral) intolerance, did not have intractable abdominal pain, did not have persistent nausea / vomiting, did not have persistent dehydration, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decompensated heart failure
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is the case of an adult patient that presented to the hospital complaining of chest pain, shortness of breath and orthopnea. Past medical history was relevant for hypertension, atrial fibrillation, and systolic congestive heart failure. On arrival, blood pressure (BP) was elevated (175/117) and pulse was irregular at 74 beats per minute. Physical exam revealed poor air movement, labored respirations, and pedal edema. 12 lead electrocardiogram (EKG) revealed atrial fibrillation with a rapid ventricular rate of 129. Pro-B type natriuretic peptide (BNP) was elevated [4090 picograms per milliliter (pg/ml)]. Chest x-ray revealed cardiomegaly and pulmonary vascular congestion. The patient was treated with intravenous (IV) diuretic therapy and bilateral positive airway pressure (BIPAP) therapy. She was admitted to the hospital for treatment of decompensated heart failure. Echocardiogram revealed a severely depressed ejection fraction of 30-35 percent (%) with anterior segmental wall akinesis. Cardiac catheterization was performed via the right femoral artery and demonstrated normal coronary arteries. The procedure was complicated by syncope that appeared to be due to a hypotensive episode and resolved spontaneously. An external life vest defibrillator was ordered, and the patient was stabilized on guideline directed medical therapy.

This patient presented with complaints of dyspnea and orthopnea. Upon presentation, physical exam and laboratory testing confirmed fluid overload due to systolic congestive heart failure. She required treatment with IV diuretic therapy and was ultimately discharged on oral guideline directed medical therapy. Failure to admit and treat this patient would have resulted in excess morbidity or even mortality. Patients with chronic congestive heart failure have a high risk of adverse outcomes warranting a higher level of care. [1] In one study, patients presenting with congestive heart failure and an elevated BNP level were found to have an increased morbidity and mortality in the subsequent 90 days. [2] In conclusion, this patient had decompensated congestive heart failure and an elevated BNP level. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for an inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke
Treatment: Hospital admission
The insurer denied coverage for a hospital admission.
The denial is upheld.

This case involves an adult patient who presented to the Emergency Department (ED) with a 2-day history of right facial weakness. The patient also complained of headaches and numbness in the right face. The patient was unable to tightly close the right eye. A family member stated that a right facial droop was noticed earlier that day. Physical exam noted minor paralysis. A Computed tomography (CT) scan of the head revealed no acute intracranial process. Computed tomography angiography (CTA) of the carotid arteries noted no evidence of occlusion or aneurysm. A chest X-ray noted no acute cardiopulmonary process. An electrocardiogram (EKG) showed normal sinus rhythm and no acute ischemia. The patient was recommended for admission for possible stroke like symptoms including facial droop. The history and physical was completed and reported that the patient had a similar presentation in the past for Bell's Palsy. It was noted that the patient was not a candidate for Tissue Plasminogen Activator (tPA) as symptoms improved. Consultation stated the patient's prior episode of facial drooping was left-sided. The patient now presented with right-sided symptoms. The provider noted the patient likely had Bell's Palsy related to poorly controlled diabetes. The hemoglobin A1c (glycated hemoglobin) was noted at 12.7. Treatment plan included antiviral medications and additional labs. The patient was discharged to follow-up as an outpatient with neurology.  

Milliman Care Guidelines (MCG) recommends inpatient admission for acute ischemic stroke with neurologic findings when National Institutes of Health (NIH) Stroke Scale score is greater than 2, evidence of hemorrhage on Computed tomography formation, altered mental status, dysphagia that warrants evaluation, significant arm or leg weakness, aphasia, gait impairment, finding on brain imaging that requires inpatient care, and/or clinical stability is unclear. 

In this case, the patient presented to the emergency department with stroke like symptoms; however, it was noted the patient had similar left-sided symptoms in the past and was diagnosed with Bell's Palsy. The patient was initially worked up and diagnostic studies included CT scans which did not reveal any significant findings. The patient was evaluated by neurology and noted to likely have Bell's Palsy symptoms related to poorly controlled diabetes. Neurology recommended follow-up treatment as an outpatient. In this case, there was a lack of documentation of clinical instability to warrant inpatient level of care. The documentation supports that the patient could have been seen, worked up and treated at a lower level of care including observation. Therefore, the hospital admission is not considered medically necessary for this patient. 

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. The medical necessity for hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Infection
Treatment: Inpatient Hospital
The health plan denied: Inpatient Hospital Admission
The determination is: Upheld

The patient is a female with a history of an uncomplicated vaginal delivery one week ago who presented with 4 days of emesis and epigastric pain. Her vital signs showed that she was afebrile with a blood pressure of 120/82 millimeters of mercury (mmHg), a heart rate of 72 beats per minute (bpm), a respiratory rate of 22/minute, and a room air pulse oximetry of 100%. Her labs showed a creatinine of 0.9 and a carbon dioxide (CO2) of 26. A urinalysis was cloudy, with 25-50 white blood cells (WBC), 5-10 red blood cells (RBC), moderate bacteria, and large esterase. A computed tomography (CT) scan of the abdomen and pelvis showed bilateral pyelonephritis or renal infarcts and postpartum state. She was admitted for possible urinary tract infection and inability to tolerate oral intake. She was given ceftriaxone for two days and then discharged home on oral cefdinir.

At issue is the medical necessity of the inpatient hospital admission. The health plan's determination of medical necessity is upheld in whole.

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with abdominal pain, nausea, vomiting and decreased oral intake after an uneventful vaginal delivery. She was hemodynamically stable. She did not have severe or persistent nausea or vomiting beyond what could have been managed at an alternate level of care. She did not have bacteremia. She did not have acute kidney injury. She did not have severe pain that required inpatient admission. She did not have altered mental status. She had no documented immunosuppression, ureteral obstruction, impaired bladder emptying, renal abscess, or emphysematous pyelonephritis. Therefore, the inpatient hospital admission was not medically necessary.