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

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Stay. 

The health plan denied the inpatient stay as not medically necessary. The reviewer overturns the determination in whole. 

This is the case of a patient who presented to the emergency department with a complaint of epigastric pain. The patient was found to have an elevated bilirubin, mild common bile duct dilation, and some gallbladder inflammation and was admitted as an inpatient with the diagnosis of choledocholithiasis. Gastroenterology was consulted and an endoscopic retrograde cholangiopancreatography (ERCP) was planned. The surgical team also planned to do a cholecystectomy during the admission. However, the patient ultimately passed the stone, and 2 days after presentation the patient's bilirubin was down-trending and the symptoms had improved. The patient was discharged with plans for an outpatient cholecystectomy. 

The inpatient stay was medically necessary for this patient. The standard of care among doctors is to admit patients with acute choledocholithiasis to an inpatient setting. 
This is a patient with choledocholithiasis. While the presentation was of uncomplicated choledocholithiasis, it could easily have become complicated, meaning either the development of cholangitis or pancreatitis. Either of those 2 conditions can be fatal and would require inpatient admission. Choledocholithiasis is usually treated as an inpatient admission by surgeons, as it is unlikely that the patient will be able to be discharged within 2 midnights. In addition, the concern for development of cholangitis and pancreatitis is very high. Choledocholithiasis is usually treated either with ERCP or by performing intraoperative cholangiography at the time of cholecystectomy, possibly with a common bile duct exploration. This is what the team had planned. However, in this case, the stone passed before that happened. Nevertheless, the patient was admitted for choledocholithiasis, which should be an inpatient admission. 

Patients can deteriorate rapidly, as they can commonly develop cholangitis or pancreatitis. Although an ERCP or cholecystectomy were not performed during the admission, the diagnosis of choledocholithiasis was no less worthy of an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain, Nausea, Vomiting.
Treatment:  Inpatient Admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male.  His medical and surgical histories were negative.  The patient presented to an emergency room with a three-day history of abdominal pain, nausea, and vomiting.  His vitals were:  temperature 37.0, pulse 99, blood pressure 110/72, respirations 16, and oxygenation 96%.  Physical examination demonstrated tenderness-to-palpation of the right-lower-quadrant of the abdomen.  Serum laboratories demonstrated leukocytosis to 12.44.  Computed tomography (CT) demonstrated acute, non-perforated, appendicitis. 

The patient was admitted at an acute inpatient level-of-care for acute, non-perforated, appendicitis.  He was made nil per os (nothing by mouth [NPO]) and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. 

He underwent laparoscopic appendectomy.  Surgery and recovery were uncomplicated, though the appendix perforated intra-operatively. 

Having returned to his baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up. 

No, the proposed treatment was not medically necessary. 

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al.; Cross et al.; Cosse et al.].  Most patients can be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission, even on observational status [Mitchell et al.; Dubois et al.; Cash et al.].  Therefore, for this patient, there was no need for admission at an acute inpatient level of care; he could have been treated at a lower level of care. 

Patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room.  The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest 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 diabetes mellitus (DM) type I, endocarditis, major depressive disorder (MDD) and multi-drug abuse and was admitted with complaints of (c/o) atypical chest pain after a heroin injection. The patient was noted to be low risk via a HEART [History, Electrocardiogram, Age, Risk Factors, Troponin] score. Vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for leukocytosis, hyperglycemia, normal bicarbonate, and a negative troponin. A chest x-ray (CXR) showed no acute pathology. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with chest pain and treated with serial troponins, telemetry, insulin, and intravenous fluids (IVF). The patient requested against medical advice (AMA) discharge and psychiatry evaluated the patient, noting he was not actively suicidal and could leave hospital. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay. 

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 chest pain that was atypical and began after heroin injection. EKG did not demonstrate any acute ischemic changes. For the chest pain, the patient's HEART score was calculated by physician to be low, indicating a low risk of a major adverse cardiac events (MACE). The patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and negative cardiac biomarkers, no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies. The patient did have hyperglycemia, but without complications or acidemia, and thus did not necessitate an inpatient level of care for treatment. This patient was admitted for chest pain and treated with serial troponins, telemetry, insulin, intravenous fluids (IVF), and psychiatry consultation, and this could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Polyarthritis, Vision loss, and Heart failure.

Treatment: Consumer Directed Personal Assistance Program (CDPAP) services at 14.5 hours per day, 7 days a week for a total of 101.5 hours per week. 

The insurer denied coverage for CDPAP services at 14.5 hours per day, 7 days a week for a total of 101.5 hours per week. 

The denial is overturned. 

This is a female patient who has an extensive medical history, substantial functional impairment and requires total care for daily activities. She lives with her daughter. The patient is approved for Consumer Directed Personal Assistance Program (CDPAP) services 66.5 hours per week. The daughter is the CDPAP aide. Request for increase of services to 101.5 hours per week, 14.5 hours per day was denied by the insurer. 

The most recent Uniform Assessment System (UAS) report indicated the patient was totally dependent in all instrumental activities of daily living (IADLs), except managing medications (maximal assistance). The patient needed maximal assistance or was totally dependent for all activities of daily living (ADLs). The patient was unable to walk and locomotion indoors was by wheelchair. It appears the patient was mostly bedbound. The patient had a recent hospitalization. The patient's functional impairments that preceded the hospitalization were probably due to various factors from several chronic medical conditions including: dementia, polyarthritis, vision loss, and heart failure. 

Considering the patient's medical history, symptoms, and functional status, it is medically necessary for the patient to have caregiver assistance for all daily activities when needed at various scheduled and unscheduled times throughout the day and night. Without adequate caregiver assistance through the day and night, the patient is at risk for skin damage due to incontinence and pressure. The advocate's report indicates the night activity logs demonstrated the patient needed assistance with toileting related tasks at least 4 times through the night. The patient needs repositioning on a regular basis for pressure relief (every 2 hours as per physician's instructions); and as needed for relief of pain/discomfort. The advocate's report indicates that the family is requesting CDPAP services 14.5 hours per day and will provide additional care during the other hours of the day as informal care. This plan appears acceptable as it provides caregiver support day and night through combination of CDPAP services and informal caregiver assistance.

CDPAP services 14.5 hours per day, 7 days per week; total of 101.5 hours per week is medically necessary. 

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

The carrier's denial of coverage for the requested CDPAP services at 14.5 hours per day, 7 days a week for a total of 101.5 hours per week is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inversion deformity
Treatment: Custom foot orthotics
The insurer denied the Custom foot orthotics.
The denial is upheld. 

The patient is an male who presented with difficulty ambulating and inversion deformity of the forefoot bilateral. His ankle was noted to roll laterally. He had outgrown his existing orthotics, and custom orthotics with lateral wedges were ordered to position his foot correctly.

No, the custom foot orthotics are not medically necessary.

The patient is healthy, and he has no muscular disorders such as cerebral palsy, paralysis. He has mild hyper pronation, which can be treated with over the counter inserts and braces.

The patient's condition may be treated with over the counter orthotics. Custom molded orthotics have not been to be more beneficial for this condition than over the counter orthotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pre-syncope.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a male patient with a past medical history of asthma.  The patient presented to the Emergency Department (ED) with subjective complaints of dizziness and lightheadedness for 3 days.  The patient stated that he felt dizzy, fell, and hit his head on the floor without loss of consciousness.  The patient's physical examination revealed a blood pressure of 123/80, and pulse of 89, and with no focal deficit.  The patient was alert and oriented to person, place, and time.  The patient had rapid alternating movements that were intact, point-to-point testing was intact, and heel-to-shin testing was intact bilaterally.  The patient's cerebellar function was intact.  The patient had a negative non-contrast Computed Tomography (CT) scan of the brain.  The patient's laboratory studies revealed a troponin that was negative.  The patient was given a dose of Tylenol and 250 milliliters (mL) bolus of normal saline.  The patient was evaluated by cardiology service for acute coronary syndrome (ACS).  The patient was admitted to the floor from observation for evaluation of pre-syncope.  The patient's transthoracic echocardiogram (TTE) revealed no acute cardiac abnormalities.  The patient took Meclizine and reported some symptomatic relief.  Neurology service was consulted and evaluated the patient, and they recommended a magnetic resonance imaging (MRI) of the brain. However, the patient felt claustrophobic so it was not performed.  The Holter monitor was deemed non-emergent.  The patient was educated on outpatient follow-up for cardiology and neurology.  

Based on the review of the medical record and literature, the inpatient admission was not medically necessary for this patient.  The patient developed a transitory dizziness with normal neurological examination.  The patient was stable during his hospitalization.  According to the patient's records, there was no clear evidence of an acute change in the patient neurological examination suggestive of acute stroke, and there was no acute motor, sensory or visual deficit that was suspicious for an acute stroke.  There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure.  There were no clinical findings that warranted an inpatient, acute level of care.  Therefore, the inpatient care admission was not medically necessary for this patient.

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

The inpatient admission was not medically necessary for this patient.

The medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Constipation
Treatment: Amitiza 8 mcg, 120 capsules per month
The insurer denied Amitiza 8 mcg, 120 capsules per month.
The determination is upheld.

The patient has chronic constipation. She notes 1-2 bowel movements per week; she also reported bloating and severe abdominal cramps. She failed Senokot two tablets twice daily, Metamucil, and Miralax. She was prescribed Amitiza 16 micrograms (mcg) twice daily as a starting dose, as well as magnesium oxide and a probiotic. The medical necessity for Amitiza 16 mcg twice daily is under review.

The American Gastroenterological Association Medical Position Statement on Constipation states that osmotic laxatives should be attempted before a newer agent such as Amitiza, with more adverse effects, is used [1,2]. In this case, fiber, a stimulant laxative (Senokot), and an osmotic laxative (Miralax) have failed, and the use of an advanced therapy such as Amitiza is supported. However, a dose of 24 mcg is recommended in the United States Food and Drug Administration (FDA)-approved prescribing information for Amitiza when used for the indication of chronic idiopathic constipation [3]. This is based on multiple clinical trials showing safety and efficacy [4-6]. 

The medical necessity of Amitiza 16 mcg twice daily is not supported as medically necessary for the indication of chronic idiopathic constipation based on the submitted documentation. A dose of 24 mcg is recommended in the United States Food and Drug Administration (FDA)-approved prescribing information for Amitiza when used for the indication of chronic idiopathic constipation [3]. This is based on multiple clinical trials showing safety and efficacy [4-6]. A lower dose of 8 mcg twice daily is recommended for the treatment of irritable bowel syndrome, constipation-predominant; that is not the specified indication in this case. No medical reason to support the use of dosing at 16 mcg twice daily is provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive emergency.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is overturned. 

This is a female patient with a previous history of hypertension who presented to the hospital with hypertensive emergency.  The patient noted a headache and bilateral upper extremity numbness.  The patient's blood pressure on presentation was 174/109 despite amlodipine therapy.  The patient was admitted to the pediatric intensive care unit (PICU) and was started on a nicardipine drip. Escalating doses of amlodipine were required to achieve good blood pressure control.  Work-up for secondary causes of hypertension included a renal ultrasound that demonstrated right kidney hydronephrosis and a magnetic resonance imaging (MRI) that revealed a mass infiltrating the bladder and right parametrial tissues.  The patient's urine metanephrine was not noted to be elevated. However, the patient's plasma renin levels were significantly elevated.  The oncology service was consulted to assess the infiltrating pelvic mass and serum blood testing for tumor markers were sent prior to planned laparoscopic biopsy.  Ultimately, the patient was discharged home with good blood pressure control, treated with amlodipine daily and angiotensin-converting enzyme (ACE) inhibitor therapy.

Based on the review of the medical record and literature, the inpatient admission was medically necessary for this patient.  This patient presented with a hypertensive urgency, headache and bilateral arm numbness.  Hypertensive emergency is defined as blood pressure greater than 180/120 with target organ damage.  In this patient, bilateral upper extremity numbness and headache was concerning for target end organ damage.  The patient was admitted to the hospital for hypertensive urgency and treatment with intravenous (IV) nicardipine was indicated.  Additional work up for secondary causes of hypertension was appropriately performed and identification of an infiltrating pelvic mass and hyper-reninemia for this patient.  Additional diagnostic testing transpired and involved nephrology, oncology, and surgical services.  In conclusion, it was appropriate to manage this patient at this inpatient, acute level of care. 

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

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

Diagnosis: Tooth fracture
Treatment: Crown on tooth #29
The insurer denied the crown on tooth #29.
The denial is upheld. 

The patient is a male requesting benefits for a crown on tooth #29.

No, the D2750 - Crown: porc to gold tooth #29 is not medically necessary with the documentation provided.

There is no fracture or decay seen in tooth on the panorex x-ray. Mesio-distal fractures, as the one described by the provider, cannot be seen on an x-ray, especially not a panorex x-ray, which is the only pre-op x-ray provided. The other two x-rays are post op with the crown already in place. The only way to see what the provider claimed (a mesio-distal fracture in tooth #29) would be a pre-op photo. This was not provided. Based upon the inability to see any fracture in the tooth, there can be no benefits for the requested crown.

There are no documents proving the need for a crown on #29.
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 has a history of end stage renal disease (ESRD) due to focal segmental glomerulosclerosis (FSGS) status/post (s/p) renal transplant, hypertension, and chronic kidney disease (CKD) who presented to the hospital with severe upper right quadrant abdominal pain for 10 hours. He denied nausea, diarrhea, positive (+) forced emesis; he had no hematemesis, no shortness of breath (SOB), no chest pain, no fevers or chills. Vital signs on presentation showed that he was afebrile, with a blood pressure of 187/115, a heart rate of 92, a respiratory rate of 16 and a room air pulse oximetry of 97%. On exam, he was well appearing with bowel sounds in all 4 quadrants, + epigastric and right upper quadrant abdominal tenderness without masses. Lab results showed a creatinine of 2.57, a potassium of 3.7, a bicarbonate of 24, a white blood cell count (WBC) of 11.2, a hemoglobin of 11.7, a lipase of 56 and normal liver function tests. An abdominal ultrasound showed marked distention of the gallbladder without stones or wall thickening. A surgery consult was obtained and felt there was not a need for a surgical intervention and they recommended admission for pain management and interventional radiology (IR) consult for percutaneous cholecystostomy tube placement. IR consulted  and felt he was hemodynamically stable and did not need urgent tube placement. The patient was discharged home in stable condition  with follow up with his primary care physician, nephrology, gastroenterology and general surgery for a possible elective cholecystectomy. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The patient presented with acute onset of right upper quadrant abdominal pain. He was hemodynamically stable at the time of presentation. He did not have signs or symptoms of an infection. He did not have signs of sepsis, he did not have acute renal failure, he did not have an acute abdomen, evidence of a ruptured or dissecting abdominal aneurysm, ischemic colitis, a ruptured viscus, acute ascending cholangitis or need for an inpatient surgical procedure. His symptoms improved overnight and he was discharged in stable condition. He could have been managed safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain and vomiting.
Treatment:  Inpatient admission.
The insurer denied the inpatient admission.  The denial is upheld.

The Inpatient admission was not medically necessary.

This patient is a female with Type I diabetes on insulin pump therapy.  She presented with nausea, vomiting, abdominal pain, and hyperglycemia. 

The patient's BP (blood pressure) was 105/70, heart rate 122, and O2 (oxygen) saturation 99%.  The patient was alert and oriented.  Her glucose was 716 mg/dL, pH 7.28, and CO2 (carbon dioxide) 15.  Her creatinine was 1.1, and WBC (white blood count) 16.6. 

The patient was admitted to ICU (intensive care unit) and treated with insulin drip and then transitioned to subcutaneous insulin.  Her CO2 (carbon dioxide) was 21 and glucose 213 on the next day at 06:27.  On that same day, she was noted to be on current diet of 45 grams with fair appetite.   

This patient had moderate diabetic ketoacidosis.  Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness such as sepsis [1], which is not documented in this case.  This patient did not have alteration in her mental status.  She was documented to be alert and oriented at time of presentation.  She had documented leukocytosis, but she did not have a documented infection and did not meet criteria for sepsis.  She responded very quickly to intravenous hydration and insulin therapy.  Her acidosis resolved overnight, and her glucose levels responded quickly to insulin therapy, and she was transitioned to subcutaneous insulin therapy on the day after admission.  She was hemodynamically stable.  She had tachycardia, which resolved quickly with intravenous hydration.  She presented with nausea and vomiting but was transitioned to taking oral intake with a fair appetite documented on the day after admission.  Therefore, the proposed inpatient stay was not medically necessary.