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

Diagnosis:  Wolff Parkinson White syndrome.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This patient with a history of Wolff Parkinson White syndrome underwent catheter ablation of a left-sided atrioventricular accessory pathway.  The procedure was uncomplicated.  Post-procedure she complained of nausea and mild dyspnea.  She was mildly hypotensive (minimum blood pressure 88/66 millimeters of mercury (mmHg)).  Her physical exam and electrocardiogram were unremarkable.  She was treated with intravenous fluids, ondansetron and Protonix.  She was discharged.  The medical necessity for an inpatient admission is under review.

An inpatient level of care was not medically necessary.  This patient underwent uncomplicated catheter ablation of a left-sided atrioventricular accessory pathway.  Same-day discharge after uncomplicated ablation of supraventricular tachyarrhythmias has been shown to be safe.  Marijon et al. analyzed data from 1342 patients, who underwent radiofrequency catheter ablation.  Of these 1342 patients, 94.6% of patients were discharged home the same day of the procedure.  The one month readmission rate was 0.79%; there were no life threatening complications.  Theodoreson et al. published a retrospective review of 897 who underwent radiofrequency catheter ablation of supraventricular arrhythmias, 805 of whom were discharged home the same day.  Among all patients with a same-day discharge, none had a subsequent complication that would have been detected had they remained in the hospital overnight.  Given this patient's nausea and mild hypotension, she could have been observed overnight.  However, this did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke with residual weakness and cognitive impairments
Treatment: PCA Level II: 12 hours per day, seven days per week; 12 hours per day, seven days per week (split shift) - 168 hours/week 
The insurer denied the PCA Level II: 12 hours per day, seven days per week; 12 hours per day, seven days per week (split shift) - 168 hours/week. 
The denial is overturned. 

The patient is a female with a history of stroke with residual weakness and cognitive impairments. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in Personal Assistance Services from 56 to 168 hours/week to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services from 56 to 168 hours/week is deemed medically necessary. 

Recent documentation from provider indicates that due to progressively worsening cognitive impairment/dementia and worsening gait ataxia/frequent falls, the patient now requires 24 hour around the clock care. Hence, the currently approved plan of 56 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services from 56 to 168 hours/week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Circumcision
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented for a circumcision under general anesthesia. The procedure had a 7:30 start time; the case was uneventful.
He developed bleeding at the surgical site in the post-anesthesia care unit (PACU) mid day and stayed in PACU essentially all day. He was described as inconsolable with saturated dressings around the circumcision site that did not stop with the first application of Surgicell and pressure. He required additional Surgicell and pressure by the attending surgeon. Ultimately due to pain and a concern for the inability to easily remove the soaked dressing, the patient was admitted overnight. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary due to the need for treatment of pain, cardiorespiratory monitoring and monitoring for response to hemostatic therapy. Pediatric patients with bleeding after a circumcision are difficult to manage and sometimes require return to the operating room. This child may have required narcotics overnight as he did during the afternoon and that would not have been appropriately done in an observation setting without proper monitoring. This patient had inadequate pain control and bleeding after surgery.

The health plan's determination is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay. 
The denial is upheld.

The patient presented to the emergency department (ED) with a history of progressively worsening abdominal pain of 4-5 days duration. Evaluation included a physical exam, labs, and a computed tomography (CT) scan. She was without a fever at the time of presentation. Vital signs were normal. Lab data identified a white blood cell (WBC) count of 12.7 thousand (K). A CT scan yielded the diagnosis of acute appendicitis without perforation. Treatment was initiated with intravenous (IV) fluid and antibiotics. A surgical consultation was obtained.
The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, appendicitis. She was provided IV fluid and perioperative antibiotics. Vital signs remained normal following ED presentation. She tolerated a diet following surgery and was discharged from the hospital.

No, inpatient care was not medically necessary in this case. The patient presented to the ED with acute appendicitis and underwent an appendectomy.
The pre- and post-surgical course was uncomplicated. Her vital signs remained normal. Her diet progression was tolerated following surgery. The records support that this patient could have reasonably and appropriately been treated at a lower level of care. This lower level of care would have permitted pre-surgical assessment, operative treatment, post-surgical monitoring, diet progression, overnight care, and provision of antibiotics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/ Kidney Disorder
Treatment: Inpatient Hospital
The insurer denied The inpatient hospital stay 
The denial is overturned in whole

 Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient at an acute inpatient level of care.
 The review of the medical records clearly demonstrated that the patient presented with a urinary tract infection that led to the evolving sepsis.
The patient clearly met the systemic inflammatory response syndrome (SIRS) criteria for sepsis. In addition, the patient's urinalysis was suggestive of the presence of a urinary tract infection.
In general, sepsis represents a spectrum of disease with mortality risk ranging from moderate (eg, 10%) to substantial (eg, > 40%), depending on the various pathogen and host factors along with the timeliness of recognition and provision of appropriate treatment.

The general principles of treatment of sepsis include:
1) Perfusion restoration with IV fluids and sometimes vasopressors; 2) Oxygen support; 3) Broad-spectrum antibiotics; 4) Source control; 5) Sometimes other supportive measures

Considering the fact that the patient's presentation was suggestive of evolving sepsis, the admission at the acute inpatient level of care was warranted to provide adequate treatment with intravenous antibiotics and intravenous fluids, and for close monitoring and signs of possible deterioration.
It was crucial to identify the source of sepsis, including the identification of the bacteria causing the infection.
Reportedly, during the hospital stay the patient developed diarrhea and required immediate workup for Clostridium difficile infection since the continued diarrhea could contribute to hemodynamic instability.
It was also important to see if the patient had Clostridium difficile infection, especially in the setting of continuous treatment with antibiotics.
In the most efficient and safe way, this type of care could have been provided in acute inpatient settings.
  Therefore, the patient required treatment with intravenous antibiotics and intravenous fluids, close monitoring for hemodynamic instability, as well as close follow-up on the culture results to identify the bacteria causing the infection and adjust the antibiotics accordingly.
As was mentioned previously, the patient developed diarrhea in the setting of treatment with intravenous antibiotics, therefore he required immediate workup for possible Clostridium difficile infection.
It was very important to know if the patient had a Clostridium difficile infection since he required a continuation of treatment with antibiotics.
Taking into consideration all these facts, the severity of the patient's condition and the complexity of the services provided justified admission at the acute inpatient level of care
Appeal type: Medical necessity
Decision: Upheld

Digestive System/gastrointestinal
Inpatient hospital

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

The patient is a previously healthy male who presented to the emergency department (ED) with a history of progressively worsening abdominal pain of 1-day duration. His evaluation included physical exam, labs, and a computed tomography (CT) scan. He was without fever at the time of presentation. Vital signs were normal. Lab data identified a white blood cell (WBC) count of 15 K. The CT scan yielded the diagnosis of acute appendicitis without evidence for perforation. 

The inpatient hospital stay is not medically necessary. The records indicate that this patient presented to the ED with acute appendicitis and underwent an appendectomy. In this case, the diagnosis of appendicitis was supported by presenting symptoms, exam findings and diagnostic results (labs and CT scan). An appendectomy was also appropriately performed. However, the records support that this patient's care could have been provided at a lower level of care and did not require an inpatient designation. The patient was clinically stable at the time of presentation. The appendectomy was performed without complication and the post-surgical recovery was without incident. The care and treatment provided could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer /Melanoma
Treatment: Lab work/blood tests 
The insurer denied DecisionDX melanoma assay 
The denial is uphold, in whole the health plans determination of medical necessity.

No, the Decision Dx Melanoma testing is not medically necessary. There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma. Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions. Further, the clinical practice guidelines from the National Comprehensive Cancer Network (NCCN) recommend against routine prognostic testing for low versus high metastatic risk outside of a clinical trial. The standard prognostic indicators for melanoma include age, gender, Breslow thickness, ulceration, and mitotic rate. Gene expression profiling has not been shown to have independent prognostic value within the context of the other known prognostic factors for melanoma. Its independent prognostic value has not been confirmed in a large population of patients with average to low-risk disease.
 It is a melanoma's histopathological features, not the decision DX melanoma gene profiling assay, that is recognized by healthcare organizations and specialist to be proven and appropriate information to properly stage and initially treat a malignant melanoma Per Boland & Gershenwald (2016), "Although now commonplace in contemporary cancer care, the systematic approach to classification of disease-specific cancers into a formalized staging system is a relatively modern concept. Overall, the goals of cancer staging are to characterize the status of cancer at a specific moment in time, risk stratify, facilitate prognostication, and inform clinical decision making. The revisions to the American Joint Committee on Cancer (AJCC) melanoma staging system over time reflect changes in our understanding of the biology of the disease. Since the 1st edition, where tumor thickness was defined anatomically by its relationship to the reticular or papillary dermis (Clark level) as well as tumor thickness (Breslow thickness), there have been significant strides in our use of clinicopathological variables to stratify low- versus high-risk patients. Management of the regional nodal basin has also changed dramatically over time, impacted by techniques such as lymphatic mapping and sentinel lymph node biopsy (SLNB) and changes in pathological evaluation of the regional lymph nodes." Therefore, based on the submitted guidelines, clinical information, and lack of support for its use in nationally recognized healthcare organizations and peer-reviewed medical literature, the decision DX melanoma assay is considered not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioblastoma multiforme.
Treatment: E0766 - Electrical tumor treatment field therapy.
The insurer denied the E0766 - Electrical tumor treatment field therapy.
The denial is overturned.

The patient is a male with history of facial droop on the left. He was found to have a GBM (glioblastoma multiforme) in the right frontal region. The patient underwent resection and glial wafer placement. The patient underwent radiation and Temodar. 

The patient has undergone Optune previously. Repeat MRI shows new enhancing lesion in the right basal ganglia, left posterior frontal lobe, left temporal lobe and left midbrain as well as possible dural metastatic extension. Recent soft tissue biopsy shows sarcoma. The patient was using Optune device but developed severe pain near the soft tissue mass. The patient is now recommended continued use of Optune device with Temodar.

Yes, the E0766 - Electrical tumor treatment field therapy is medically necessary. 

The patient had used it for several years, and it was providing reduction in recurrence. The patient then developed metastatic extension of GBM which are inoperable. The use of Optune in this setting is medically necessary, because this patient had been using Optune with good clinical results, and the NCCN guidelines also support its use. The use of Optune in this patient who has progression of his disease which is not amenable to surgery, is the best option in combination with Temodar and has been shown to be the best option for patients like this one and is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial was upheld.

This is a female patient with a history of morbid obesity, diabetes, hypertension, and obstructive sleep apnea (OSA). The patient presented to the Emergency Department (ED) with complaints of fever, chills, diarrhea, and abdominal pain. It was reported that the patient had recent bariatric surgery. On exam, the patient was afebrile with a blood pressure of 94/55 and heart rate of 85. The patient appeared well developed and in no acute distress. The patient's abdomen was noted to be non-tender to palpation. The patient's white blood cell (WBC) count was 9.2 and hematocrit was 35.6. The patient's creatinine was 1.45. The patient's sodium was 131, potassium was 3.2 and glucose was 106. Surgery was consulted for evaluation. The plan was to admit patient for dehydration in setting of recent gastric sleeve surgery. Surgery noted that the patient had consumed some veggie soup at an outside restaurant 2 days ago after which she started to have loose watery bowel movements, 8 episodes. Exam by surgery was unremarkable. The plan was to give the patient intravenous (IV) fluid boluses and repeat labs for the following morning. After a period of medical stability the patient was discharged home.

According to the MCG Health Inpatient and Surgical Care - Gastroenteritis ORG: M-170 (ISC), inpatient admission is indicated for one or more of the following: 1) Suspected severe infection (e.g., bloody diarrhea, immunosuppressed); 2) Severe abdominal pain; 3) Peritoneal signs; 4) Toxic megacolon; 5) Hemodynamic instability; 6) Vomiting that is severe or persistent dehydration that is severe or persistent; 7) Electrolyte or metabolic abnormality that is severe or persists despite observation care (e.g., acidosis, alkalosis, hyponatremia, hypernatremia); 8) Hemolytic uremic syndrome; 9) Inability to maintain oral hydration (e.g., needs IV fluid support) that persists after emergency department and observation care treatment. In this case, this patient did not have severe electrolyte abnormalities or hemodynamic instability that could not have been managed with hydration at an observational level of care. 

Based on additional review of the MCG Health guidelines for electrolyte disorder and gastroenterology, this patient's case did not present with electrolyte abnormalities that warranted inpatient level of care. The patient did not have altered mental status, weakness or worsening renal function. The patient could have been treated as observation status and then, be discharged home within 23-hour of hydration. The patient did not have an acute issue that could not have been treated in an observational setting. Thus, inpatient 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.

Based on the above, 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: Rule out rule out deep vein thrombosis (DVT)/pulmonary embolism (PE) and congestive heart failure (CHF)

Treatment: inpatient admission

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

This patient is a female with history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), and morbid obesity who presented to the emergency department (ED) with complaints of increasing swelling of both lower extremities and increasing dyspnea on exertion over several months. The patient has also noted a 50lb weight gain over the past few months. The patient had been prescribed compression stockings by her primary physician but she had not been using them. Vital signs at presentation to ED: Temperature 97.9 F, Heart Rate 93, Respiratory Rate 18, Blood Pressure 184/84 mm Hg, oxygen (O2) saturations 99%. The patient was awake and alert with no jugular venous distension, lungs were clear, cardiovascular system was normal, and there was bilateral pitting pedal edema with skin pigmentation noted.

White blood cell (WBC) was 8.2K, Hb 8.5, BUN/ Creatinine 28/1.45, Troponin was 0.01, EKG No acute ischemic changes Pro BNP elevated to 131D Dimer was elevated to 281.Chest x-ray revealed (CXR) some perihilar and left lower infiltrate. No pleural effusion. The patient was admitted to rule out rule out deep vein thrombosis (DVT)/pulmonary embolism (PE) and congestive heart failure (CHF). The patient was given Lasix in ED and 1 dose of Levaquin even though pneumonia not likely given normal WBC and there was no fever or other clinical signs of pneumonia. A DVT study was negative for DVT of the lower extremity, V/Q scan was read as low probability of PE. ECHO revealed left ventricular hypertrophy and ejection fraction was 65%.

The patient did not need acute inpatient hospitalization. She had been on Amlodipine which may have been also contributing to patient's edema. The patient improved with Lasix. The patient was discharged the day after with outpatient follow up.This patient did not need acute inpatient hospitalization. She could have been placed in Observation while diagnostic testing and treatment were initiated. The patient had DVT and PE ruled out. The patient did not have acute CHF. She did not have pneumonia she was responding to Lasix. The patient remained afebrile and hemodynamically stable after admission to the hospital. The patient was tolerating oral intake. The patient was stable for discharge on oral medication with close follow up in the outpatient setting. She was afebrile and hemodynamically stable WBC 6.7 Hb 9.2. PE, myocardial infarction (MI) and CHF and DVT had been ruled out. The patient was saturating to 99% was awake alert lungs were clear. The patient could have been switched to oral Lasix.

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.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He has history of hypertension, morbid obesity, chronic anemia, hypertension, and stage V chronic kidney disease.  The patient presented to the hospital with worsening renal function (outpatient creatinine 13.6), for initiation of dialysis.  The patient was without complaints and was noted to have recently undergone arteriovenous fistula creation.  

The patient was afebrile with a blood pressure 175/111, pulse 85, and oxygen saturation 99%.  The examination demonstrated clear lungs and no edema.  The chest x-ray showed no acute process.  Labs were notable for a white blood cell count 5.5, hemoglobin 7.6, potassium 4.7, HCO3 (bicarbonate) 16, BUN (blood urea nitrogen) 115, and creatinine 16.7.  Hemodialysis was initiated via the arteriovenous fistula on the day of admission.  Epogen was provided for anemia.  Oral antihypertensive agents were provided.  

The patient's blood pressure improved with ultrafiltration at dialysis.  Upper extremity Dopplers, which were performed for occurrence of a hematoma at the arteriovenous fistula site, demonstrated a patent fistula without compression by hematoma.  Hemodialysis was continued.  The patient was discharged with continued hemodialysis on an outpatient basis arranged.

No, the Inpatient admission was not medically necessary.

The patient presented for elective initiation of hemodialysis and was asymptomatic.  The patient did not have medical comorbidities (such as advanced cardiovascular or pulmonary disease) requiring initiation of dialysis in an inpatient setting.  The patient did not have hyperkalemia, severe acidemias, or volume overload.  There were no uremic symptoms.  The patient tolerated hemodialysis without complication such as disequilibrium syndrome.  The elevated blood pressure on admission improved with ultrafiltration at dialysis and with oral antihypertensive agents.  There was no evidence of hypertensive emergency and no need for intravenous antihypertensive agents.  The hematoma that developed at the arteriovenous fistula cannulation site was not large and did not result in fistula compression or extremity hypoperfusion.  The patient's anemia was not accompanied by evidence of bleeding, and a blood transfusion was not required.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.