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

Diagnosis: Dizziness; Chest pain
 
Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial modified.

This patient is a female with a history of Type II Diabetes, Asthma, Hypertension, Hyperlipidemia, and gastroesophageal reflux, tobacco and alcohol dependence,  that was transported to the Emergency Room by Emergency Medical Services (EMS) for complaints of dizziness, midsternal chest pain, dyspnea, diaphoresis, nausea and vomiting.  On admission to the Emergency Room, the patient had a blood pressure of 169/93, a normal heart rate.  A battery of testing was completed.  There was a normal EKG, normal chest x-ray, CT of the head was normal, blood testing revealed low magnesium and potassium, troponin was normal with normal brain natriuretic peptide (BNP).  The patient was admitted for cardiac and neurological consultation.  An echocardiogram revealed a grade 1 diastolic dysfunction, a carotid ultrasound revealed right carotid stenosis, bilateral lower extremities Doppler ultrasound was negative.  The remainder of the cardiac enzymes were negative.  The patient was treated for the electrolyte imbalance, treated for her hypertension, and was discharged with follow up visits to the primary care physician, podiatry and ophthalmologist.

According to the MCG 23rd Edition guidelines for chest pain and dizziness, an inpatient hospitalization could have been considered for an extended period of observation of approximately 1 day (24 hours) however, there is no evidence that a 3 day inpatient hospital stay was indicated as the vast majority of the testing could have been done as an outpatient. Therefore, because a 24 hour observation would have been sufficient, the denial for coverage is partially medically necessary.  

The carrier's denial of coverage for the inpatient admission is modified.  Approve a specified date range.  Deny another date range.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain in right knee
Treatment:  Diagnostic examination of knee using an endoscope 
The diagnostic examination of knee using an endoscope was medically necessary.

This is a male with ongoing right knee pain. He had undergone a total knee replacement (TKR) previously and reported pain two weeks after surgery. He had received physical therapy (PT), bracing and medication without benefit. 

The patient's physician denoted point tenderness to a specific location. His physician opined prominence of the medial femoral condyle as the pain generator.  His physician performed arthroscopic surgery (right knee arthroscopy with burring of osteophytes).

The medical record demonstrates presence of ongoing pain and functional problems. The patient's physician has identified a possible pain generator. The report of point tenderness to medial knee can be associated with prominent tissue, scar, bone/cement fragment and or osteophyte. Imaging studies demonstrates presence of a prominent osteophyte. Based upon lack of improvement over a period of several months and localization of pathology most surgeons would recommend the arthroscopic evaluation of the knee. This would allow for exact diagnosis and treatment directed pathology encountered. 

Additional time and non-operative treatment will unlikely change current clinical course. 

Criteria for loose body have been fulfilled.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Facial Edema
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.   

This patient is a male child with history of cleft palate repair.  He presented to the Emergency Room (ER) with his father with complaints of severe facial edema and urticaria of his abdomen and trunk.  His presenting vital signs were stable, and there was no reported respiratory distress.  Prior to arrival to the ER he received epinephrine and Benadryl.  Initial vital signs were normal (blood pressure 93/50, pulse 102, respirations 26, temperature 98.7F, and blood oxygen level 100 %.  There was history of an upper respiratory infection prior to admission.  There was no respiratory or hemodynamic involvement to indicate this was an anaphylactic reaction.  In the ER Decadron and Zantac were administered with mild improvement.  He was admitted to the hospital for further monitoring of his facial edema.  However, there is no documentation at all to show that there wasn't any swelling or any rash on physical exam.  Eye and skin exam were normal throughout the ED stay, and vital signs remained normal.  His symptoms improved, and he was discharged home. 

The health care plan acted reasonably and with sound medical judgment, in the best interest of the patient.  Based upon practice guideline from the American College of Allergy, Asthma & Immunology (reference below), the patient could have been safely sent home on oral antihistamines and corticosteroids. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary and mandibular crowding
Treatment: Braces
The Comprehensive orthodontic treatment is medically necessary.

The patient has severe maxillary and mandibular crowding. He has impacted mandibular left premolars (meaning they are stuck inside the jawbone), as well as an ectopically erupted upper left canine and lower right canine. This means that these teeth are erupting in the wrong position in the jaw. This patient has a handicapping malocclusion in that due to the severe crowding in his mouth, teeth are either not erupting into place at all, or they are erupting in the wrong places. This will cause the other teeth to not mesh properly when chewing. This will cause trauma to the remaining teeth, such as fracturing or loosening over time. This patient definitely needs orthodontic treatment to make enough room for all the displaced teeth to erupt into their proper locations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a male who presented to the ER for further evaluation/management of loss of vision, dizziness, chest pressure and diaphoresis. His intake vitals were notable for moderately elevated blood pressure of 161/72, but he was otherwise afebrile and hemodynamically stable with no evidence of severe tachycardia, hypotension or hypoxemia. Head CT, EKG, chest x-ray and laboratory testing were negative for acute abnormalities, including no evidence of intracranial bleed, end organ damage, significant arrhythmia or other metabolic derangement. 

The patient was admitted to the inpatient medical service, where he received supportive care measures, including IV fluid hydration and close monitoring with frequent neuro checks. He responded well to the prescribed therapies, and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed service of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission.  
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a female. She was brought to the emergency room via EMS due to new-onset seizure. Her medical history was notable for viral meningitis, migraines, and asthma.  Her parents reported she had a seizure and was shaking and unresponsive while at home.  The patient reported she had come home from work reporting a headache that was different from her baseline headaches as well as light sensitivity. She took two Percocet and vomited shortly afterwards.  While resting in bed, her mother noted her hands were in fists and her elbows were flexed against her body. She made grunting noises and appeared stiff and her eyes were open, "but she wasn't there."  She was confused following the incident. EMS services were called.  

On exam, the patient was tachycardic and complained of headache. CT scan of the head and MRI were unremarkable. Neurology was consulted.  EEG (electroencephalogram) was suspicious for underlying seizure disorder. Admitting diagnosis was listed as new onset seizure without head trauma.  The patient was given levetiracetam and discharged the following day with instructions to follow-up with neurology. 

The patient had one seizure but subsequently was clinically stable, completely recovered in terms of alertness and consciousness. She had stable vital signs, and there was no evidence of recurrent seizures or status epilepticus or any evolving neurological deficits. The patient's brain imaging was normal as well. Practice guidelines and peer-reviewed medical literature does not support overnight admission for the cases of first unprovoked seizure. Therefore, overnight acute care admission was not medically necessary, and the patient could have been managed at a lower level of care. 

Considering that the patient was stable after her seizure and did not have status epilepticus or any neurological deficits or imaging findings, did not require any ongoing intravenous treatments or surgery or other procedures, inpatient admission was not medically necessary and therefore the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary.

The patient is a female. She presented with the complaint of difficulty producing speech. At presentation, her speech was not fluent, but she otherwise did not have any focal neurological deficits.  In the emergency ward she had a spell that was consistent with pseudo-seizure.  She had EEG (electroencephalogram), MRI and was discharged on Keppra.
 
The patient has speech difficulties, but MRI was negative for stroke. The EEG did not show seizure activity.  The diagnostic testing, treatment, monitoring and neurological consultation could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Coronary Syndrome

Treatment: Inpatient Admission 

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

This is a female patient with a history of anxiety, panic attack, and anemia.
She presented to the Emergency Department (ED) with complaints of chest pain, shortness of breath and anxiousness. Cardiology was consulted. An electrocardiogram (EKG) was performed that showed sinus tachycardia. It was reported that the patient was very agitated on exam with associated nausea and vomiting. The patient was admitted to the hospital for acute coronary syndrome and monitored on telemetry. Intravenous (IV) fluids and IV Zofran were administered. Laboratory work up was performed; troponin levels were normal. The patient was medically stabilized and discharged home with instructions for continued outpatient cardiology testing.

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

The patient presented with chest pain.  The initial evaluation in the ER was unremarkable, including nondiagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Skin disorders/Dermatitis 
Pharmacy prescription drugs

The patient is a male with palmoplantar fissuring and painful eruptions that have not responded to either topical steroids or oral Methotrexate. The patient improved on Dupixent, but the rash and fissuring are recurring and preventing the patient from doing full duties. The health plan's determination of medical necessity is overturned in whole. Yes, the requested Dupixent is medically necessary for this patient.
It does appear that the patient has dyshidrosis and not pustular psoriasis (which are often virtually the same both clinically and even histologically), and if Methotrexate (first-line for both psoriasis and atopic dermatitis with respect to systemic therapy) has failed then biologic therapy (in this case, with Dupixent) is medically necessary consistent with standards of care and current medical literature [1-4].
Restarting Dupixent is now the medically appropriate, indicated, and necessary treatment option for this patient at this time. The biologic therapy is now indicated for this patient.
According to the peer review literature, Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature (2).
Dupixent is medically necessary for this patient's symptomatic hand/foot dermatosis at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Poor visual acuity; hypertensive cardiovascular disease
Treatment:  Increase in personal care aide services from two days/week six hours/day to two days/week 24 hours/day live-in

The proposed treatment of an increase in consumer directed personal assistance services from two days/week six hours/day to two days/week 24 hours/day live-in is deemed medically necessary.

This is a female with a history of poor visual acuity/legal blindness, hearing loss, depression and hypertensive cardiovascular disease.  Due to impairments related to these conditions, she requires assistance with the majority of her activities of daily living (ADLs).  Per documentation from the patient's Attending Physician, the patient's heart condition results in chronic fatigue, dyspnea and generalized weakness, resulting in the need for 24 hr assistance for bed mobility, transfers, ambulating, toileting and fall prevention.  For these reasons, the currently approved plan of 53 hours/week consumer directed personal assistance services is insufficient to meet the patient's current medical needs.  Hence, the proposed treatment of an increase in consumer directed personal assistance services from two days/week six hours/day to two days/week 24 hours/day live-in is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Non-Hodgkin's lymphoma
Treatment:  Inpatient Hospital

The patient is a male patient who was admitted for tumor lysis monitoring with initiation of chemotherapy.  The inpatient admission is under review. 

The health plan's determination is upheld.  The inpatient admission was not medically necessary.  This patient was considered intermediate risk of tumor lysis given diffuse large B cell lymphoma.  This is due to LDH (Lactate dehydrogenase) > ULN (upper limit of normal) and not > 2 ULN, and non bulky disease.  There was no evidence of tumor lysis syndrome at presentation.  The uric acid was normal, K+ was normal, phosphorus was normal and the calcium was mildly elevated.  The patient received IVF and allopurinol.  There was no evidence of dehydration, renal dysfunction, low blood pressure or acidosis.  This patient could have been monitored at a lower level of care and transferred to inpatient if evidence of tumor lysis was seen.  Lab monitoring and urine output could have been measured at a lower level. There were no criteria fulfilled for an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Anemia
Inpatient Hospital

The patient is a male with history of metastatic prostate cancer status/post (s/p) bilateral nephrostomy tubes, hypertension, chronic obstructive pulmonary disease (COPD), deep vein thrombosis (DVT) who is currently on chemotherapy who was advised to seek care in the emergency department (ED) by his outpatient physician after his outpatient lab work revealed a low Hemoglobin.  He reported symptoms of fatigue and dyspnea on exertion and some pain with movement around his nephrostomy tube sites.  He recently had chemotherapy including cisplatin and had received outpatient Neupogen to prevent low white count.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient had chemotherapy induced bone marrow suppression as the likely cause of anemia which required blood transfusion.  This care could have been completed at a lower level of care.  There were no significant reported subjective or objective findings to necessitate an inpatient admission including patient symptoms, active bleeding, vital signs or lab work.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a female with a Class II malocclusion. She has minor crowding and anterior crossbite of tooth #6. There is some recession present on tooth #27. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion.

The health plan's determination is overturned. Braces are medically necessary. The patient has minor maxillary anterior crowding with tooth #6 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #27 already has some recession, and further movement of tooth #27 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical shortening
 
Treatment: Acute inpatient admission

The insurer denied coverage for acute inpatient admission. The denial is upheld. 
	
This patient is a female who was admitted at 24.3 weeks gestation because of cervical shortening detected on ultrasound. The patient has been maintained on vaginal progesterone and followed up with cervical length measurements. The fetus was stable. There was no bleeding, contractions, or sign of infection. The patient received magnesium sulfate for neuroprotection on day of admission and two doses of intramuscular Betamethasone. The progress notes documented that the patient was stable with no active management of the patient. The patient was discharged.

The patient had a short cervix.  She was admitted and placed on magnesium sulfate. The patient was already receiving vaginal progesterone. The patient was not in labor.
The value of hospitalization for women with short cervix has been studied and the scientific literature showed that admission to the hospital was not associated with a decreased rate of preterm delivery and there was a trend toward hospitalization as an independent risk factor for delivery at < 34 weeks, an earlier gestational age at delivery, and a shorter time from diagnosis to delivery. Hospitalization was independently associated with an increased rate of cervical shortening. Another study showed that activity restriction did not reduce the rate of preterm birth in asymptomatic nulliparous women with a short cervix.

The patient did not have any contractions. The fetal heart was reassuring. She was afebrile.  She could have been followed as an outpatient with serial ultrasound monitoring of her cervical length.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission was not medically necessary for this patient.

Based on the above, the medical necessity for the acute inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Other
Inpatient Hospital

This is the case of a female with sickle cell disease who presented to the emergency department (ED) with 4 days of chest pain, congestion, cough, and abdominal pain. There was no fever, vomiting, or diarrhea. She did admit to running out of her maintenance medication (hydroxyurea) approximately 1 month prior.
ED vitals were temperature (T) 98.4-99 Fahrenheit (F), heart rate (HR) 85-86, respiratory rate (RR) 19, blood pressure (BP) 108-113/63-71, oxygen (O2) saturation 95% on room air. Physical exam showed tenderness to palpation over the mid- and lower sternum and xyphoid process. The left elbow also showed an indurated pustular lesion. Lab evaluation showed white blood cell (WBC) count 13.3 with 57% segs and 24% lymphs, hematocrit (Hct) 24.8, platelets (Plt) 430. Electrolytes were normal; total bilirubin (Tbili) and alkaline phosphatase (Alk Phos) high at 3.2 and 175, respectively. A chest x-ray was unremarkable. An incision and drainage (I&D) was performed on the elbow abscess.
Due to the concern for acute chest syndrome, the patient was admitted to the inpatient status. She was treated with intravenous fluids (IVF), intravenous (IV) antibiotics, and IV pain control. She was seen in consultation by the hematology service who determined that she was suffering from a vaso-occlusive crisis, rather than acute chest syndrome as originally feared while in the ED. She was able to be discharged home with adequate pain control. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

Yes, based on the medical documentation provided, the requested inpatient hospitalization was considered medically necessary.
This patient with known sickle cell disease presented to the ED with several days of chest pain and associated symptoms consistent with possible acute chest syndrome: chest pain, chest x-ray concerning for new infiltrate, and room air O2 sat of 95%.  She was diagnosed and treated for concern of acute chest syndrome, which was later modified to vaso-occlusive crisis involving the sternum. The clinical concerns were clearly documented by the ED team, and the patient was admitted for IVF, IV antibiotics, pain control, and close monitoring for worsening condition. Inpatient level of care was medically necessary.