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

Diagnosis: Acute abdomen 
Treatment: Inpatient admission 

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

The patient is a female with a past medical history of gastroesophageal reflux disease (GERD), ovarian cysts, fibroids, and anemia.  The patient presented to the Emergency Department (ED) with subjective complaints of abdominal pain.  The patient's blood pressure was 120/65.  The patient's abdomen was soft with generalized tenderness.  The patient noted that she ate earlier in the day and shortly thereafter, started to experience lower abdominal pain, with a sharp-like sensation.  The patient reported that her last bowel movement was that morning. In the ED, the patient's abdominal exam revealed positive right lower quadrant tenderness, right costovertebral angle tenderness, and right adnexal tenderness; bowel sounds were normal and there was no abdominal distension.  The patient's urine pregnancy test was negative.  The impression was rule out appendicitis/colitis, rule out ruptured ovarian cyst/fibroids, rule out pyelonephritis/kidney stones and urinary tract infection. 

 The patient was to undergo laboratory studies, and was to be treated with intravenous (IV) fluids, Pepcid, and morphine.  The patient was to undergo a computed tomography (CT) scan.  The patient's CT scan of the abdomen showed normal appendix but extensive inflammatory changes with inflammatory fluid in the right lower quadrant; the terminal ileum was abnormal with irregular bowel wall thickening and mucosal enhancement. The diagnostic considerations included infectious or inflammatory enteritis including Crohn's exacerbation.  The patient was admitted for inflammatory enteritis versus questionable Crohn's exacerbation.  The patient was discharged in stable condition. 

Based on the review of the medical record, the patient presented with an acute abdomen.  The patient had leukocytosis and severe anemia of 8.2 subsequently dropping down to 6.9.  The patient's computed tomography (CT) imaging showed terminal ileal inflammation and enteritis which were suspicious for Crohn's disease.  The patient had not previously been diagnosed with inflammatory bowel disease (IBD). 

The patient demonstrated signs of acute inflammation along with blood loss.  This was a new constellation of findings and needed prompt further evaluation.  Since the findings were new and severe, there was no way to predict that this patient would improve within 24 hours to have admitted under observation.  Thus, in this clinical setting, this patient's inpatient admission was appropriate and consistent with standard of care.  Literature supports that inpatient admission was medically necessary to treat this patient's medical condition. 

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 reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epidemic keratoconjunctivitis (EKC)

Treatment: Office visits

The insurer denied coverage for office visits. The denial is reversed.

This patient is a presented with red eyes that were watery, photophobic and crusty. On exam, the patient was noted to have 2+ injection, 1+ chemises and 1+ punctate epithelial erosions in both eyes. The patient had a diagnosis of epidemic keratoconjunctivitis (EKC) and was started on treatment with prednisolone every 2 hours for 3 days, then four times a day. The patient presented for follow up. The patient's EKC was improving and prednisolone drops were tapered. The patient's intraocular pressures were noted to be 30 in both eyes.  With regards to her EKC, it was noted to be active; prednisolone drops were tapered. The patient's intraocular pressures were 29 in the right eye and 30 in the left eye; the patient's EKC was noted to be improved.  The patient's ocular hypertension did not drop after stopping prednisolone, and she was referred.

Based on the review of the medical record, the patient had evidence of epidemic keratoconjunctivitis (EKC), as noted during her visit to the optometrist.  Topical steroid (Prednisolone) was started and she was monitored during her following visits for resolution of signs and symptoms.  Studies have shown that topical steroid treatment can significantly improve EKC symptoms, and that EKC symptoms are shorter in duration and less severe when using a topical steroid like Prednisolone. 

Literature supports that each of these patient visits was medically necessary to safely treat and monitor this patient's ocular condition.  Follow up visits were necessary to ensure that this patient's ocular condition was improving, and that there were no side effects associated with the use of the Prednisolone drops. Since topical steroids can cause elevated intraocular pressure, it was medically necessary to check for intraocular pressures. The patient was noted to have elevated intraocular pressures even after stopping prednisolone. Thus, the patient was referred for further management for her ocular hypertension. 

The health care 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 office visits for dates of service should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Infectious Disease.
Treatment:  Pharmacy Prescription Drugs.
The health plan denied the Epclusa.  The denial is upheld in whole.

The patient is a male infected with hepatitis C.  He has a past history of alcohol abuse.  He has genotype 1a/b.  Viral load is approximately 300 thousand (K) international units per milliliter (IU/ml).  He is treatment naive.  The patient has compensated cirrhosis with large esophageal varices (that have never bled) and a calculated Model for End-Stage Liver Disease (MELD) score of 10.  He is human immunodeficiency virus (HIV), Hep A, and Hep B negative.  Urine toxicity screen was negative.  Hepatocellular carcinoma (HCC) screening is up to date.  By imaging and exam, he has no ascites.  He has no evidence of hepatic encephalopathy.  Normal renal function.  In the request for an anti-viral the applicant checked "compensated" cirrhosis corresponding to the other information in the clinical chart.  The patient's provider has recommended treatment with Epclusa.  This request was denied by the plan, which determined that it was not medically necessary.  The preferred formulary agent is Mavyret.

The health plan's determination is upheld, in whole.

No, treatment with Epclusa is not medically necessary for this patient.  Decompensated cirrhosis is characterized by one or more of the following: jaundice, ascites, hepatic encephalopathy, hepatorenal syndrome or variceal hemorrhage.  The patient does not have these complications and is, therefore, compensated.

According to treatment guidelines for genotype 1b-infected, treatment-naive patients with compensated cirrhosis, there are 4 recommended regimens with comparable efficacy.  Elbasvir/Grazoprevir, Glecaprevir/Pibrentasvir (Mavyret), Ledipasvir/Sofosbuvir, and Sofosbuvir/Velpatasvir [1].  The success of the plan's preferred agent, Glecaprevir/Pibrentasvir, was shown in 3 studies EXPEDITION-1,2, and 8 [2,3,4].  In all 3 studies, patients with genotype 1b, compensated cirrhosis achieved sustained virologic response (SVR) in 98-100% of cases.  In all studies the drug was given for 12 weeks.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Severe right flank pain.
Treatment:  Inpatient Admission. 

The patient is a female admitted through the ER with severe right flank pain uncontrolled with oral pain medications.  Earlier in the day she had a renal calculus treated with a percutaneous nephrolithotomy (tubeless) and stent placement.  Vitals were 99-78-116/76-17.  The WBC (white blood cell) count was 8240.  The hematocrit was 39.1. 

An acute inpatient level of care was not medically necessary.  Care could have been provided at an observation level of care.  Following the procedure, there were no unstable vital signs reported.  There were no postoperative complications reported such as sepsis, fever, bleeding, or hemodynamic instability.  Although she had pain, control of this condition with IV pain medications did not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System / Neuromuscular Disorder.
Treatment:  Inpatient Hospital.
The insurer denied the inpatient stay.  The denial is upheld in whole.

The patient is a female with a history of hypertension and hyperlipidemia.  She presented to the emergency room with a four-day history of dizziness and pressure in the back of her head.  The symptoms were made worse with head movement.  The vital signs, including the oxygen saturation were normal.  She was in no acute distress and looked well.  The physical exam, including a detailed neurologic exam, was normal by one examiner.  Another examiner noted vertical nystagmus, but this was not well documented.  Labs were notable only for a minimally decreased potassium of 3.3 and a hemoglobin A1c of 6.1%.  The Electrocardiogram (EKG) was normal.  The computed tomography (CT) scan was negative.  The neurology consultant noted some subtle nystagmus but no focal neurologic findings.  The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with her medications.  A magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of the brain was performed and were negative.  The remainder of the stay was clinically uneventful, and the patient was discharged later in the day.

The health plan's determination of medical necessity is upheld, in whole.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary.  Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints.  The history and physical were most consistent with peripheral vertigo, such as benign positional vertigo.  The likelihood of a stroke was very low.  The patient did not need to be admitted for an MRI, which could have been completed at a lower level of care status.  Based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Other 
Home health care
The patient has multiple medical problems, most notably dementia and an undiagnosed arthritic condition, which limits  ability to care for self. The main concern, according to the patient's daughter, is the patient's dementia and inability to live alone without services.
Patient is currently receiving personal care services, 6 hours a day 7 days a week.
Patient requests an increase in personal care worker service hours to 8 hours a day 7 days a week, an additional 2 hours a day. The health plan's determination is upheld in whole. Additional services will not prevent falls or change the patient's underlying medical condition of dementia/confusion.
The patient has multiple medical problems which include hypertension, dementia, diabetes, constipation, benign prostatic hyperplasia (BPH), elevated anti-nuclear antibody (ANA), anemia, and hyperlipidemia. a Uniform Assessment System (UAS) State of New York noted that the patient is self-directing with day-to-day tasks such as when the patient wants to eat or drink. Noting that the patient is able to be left alone in the home. Time Tasking Tool was noted that the patient required a total of 4 hours a day 7 days a week of services. The services provided are adequate to meet the patient's medical needs. Services include help with medically necessary ADLs and IADLs. Additional services for monitoring of dementia or for "prevention of falls" and "monitoring" without services being provided are typically not considered medically necessary. In order for services to be considered medically necessary, the aid must be performing a service such as a medically necessary ADL or IADL.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza infection
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with history of hypertension and hypercholesterolemia. He presented to the emergency room with shortness of breath (SOB). During the ER evaluation, the patient was found to be influenza A-positive. The patient had elevated D-dimer, as well as elevated BNP (brain natriuretic peptide). The CT-chest excluded pulmonary embolism but showed pleural effusions and cardiomegaly. The patient was admitted to acute in hospitalization for hypoxia in the setting of influenza A infection.

In the emergency room, the patient's oxygen saturation was 86% on room air. The patient was started on Tamiflu and Duonebs. The patient had bilateral wheezing and lower extremity edema. The patient was admitted to acute inpatient level of care for hypoxia and influenza A treatment and was continued on supplemental oxygen as well as Tamiflu and Duonebs. The following day, the patient was hemodynamically stable. The patient was weaned off oxygen to room air. The patient was continued on Tamiflu. The pulmonary consultation deemed appropriate for the patient to be discharged home. 

Provision of Tamiflu, Duonebs and oxygen would be safe, effective, and consistent with the standard of care to be provided at an observation level of care. There was no treatment provided that required an acute inpatient level of care. It would have been reasonable to expect that the patient could have been treated at an observation level of care without compromising his health, safety, or outcomes. Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.

Treatment: Inpatient admission.
 
The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of hypertension, diabetes, hyperlipidemia, hypothyroidism, morbid obesity, anxiety, depression, hysterectomy, knee surgery, laminectomy, lipoma resection and tubal ligation.  She presented to the emergency department (ED) with complaints of intermittent squeezing, tightness left sided chest pain radiating to the neck, left shoulder, shortness of breath, leg pain and headache after being involved in an argument.  The chest pain was worse with deep inspiration and palpation and non-twisting movement.  Vital signs were stable.  Troponin was negative.  Electrocardiogram showed minimal voltage criteria for left ventricular hypertrophy (LVH).  The patient was admitted for further management of chest pain rule out acute coronary syndrome.  She ruled out for myocardial infarction.  Echocardiogram showed mild left ventricular hypertrophy and minimal mitral, tricuspid and pulmonic valve regurgitation.  After treatment and once the patient was medically stable, the patient was discharged home. 

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

The patient presented with chest pain.  The initial evaluation in the Emergency Room (ER) was unremarkable, including non-diagnostic 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 was not.  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.  The observational level of care would have been appropriate.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dizziness, dyspnea on exertion, and palpitations with exertion.
Treatment:  Inpatient admission.

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

The patient is a female who had presented to the hospital emergency department with the complaints of dizziness, dyspnea on exertion, and palpitations with exertion over the preceding few weeks prior to this presentation.  The patient has a history of iron deficiency anemia (IDA), gastritis and anemia.  The patient had been referred to the ED by their primary for anemia as the patient was found to have a hemoglobin of six (6).  The patient had no gastrointestinal complaints.  The patient reported very heavy menstrual periods.  The patient had a hemoglobin of 6.1 in the emergency room.  The hemoglobin rose to 7.3 after one unit of packed red blood cells.  No inpatient evaluation was recommended by the gastroenterology consultation.  The patient was instructed to take a proton pump inhibitor (PPI) and continue iron supplements. 

No, inpatient admission was not medically necessary; the care as provided was medically appropriate, but the level at which the care was delivered was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care.  The patient had a symptomatic anemia; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  Only one unit of blood was provided, and the plan was for continued oral iron provision.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain and palpitations.
Treatment:  Inpatient admission.

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

The patient is a woman with a past medical history notable for hypertension and vertigo. She presented to the Emergency Department with complaints of chest pain and palpitations.  Vital signs were stable.  She had chest pain, which was reproducible on palpation of the chest wall.  EKG revealed an incomplete right bundle branch block.  The patient remained persistently symptomatic requiring further treatment and monitoring; therefore, she was admitted to telemetry unit.  She was ruled out for myocardial infarction with negative cardiac enzymes.  The transthoracic echocardiogram revealed mild to moderate mitral regurgitation and mild concentric left ventricular hypertrophy.  The stress test impression revealed ECG abnormalities were 1 mm uploading ST depression in II, III, aVF, and V4-V6 during exercise that resolved in recovery.  She was treated medically during her hospitalization.  After treatment and once medically stable the patient was cleared for discharge to home with follow-up.

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

The acute inpatient admission was not medically necessary.  The patient presented with chest pain.  The initial evaluation in the Emergency Room (ER) was unremarkable, including non-diagnostic 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.  The observational level of care was appropriate.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dyspnea.
Treatment:  Inpatient admission.

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

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, cerebral vascular accident (CVA), chronic kidney disease (CKD) and systolic congestive heart failure (CHF) with ejection fraction (EF) in 35-40% range.  The patient presented to the emergency room (ER) for worsening dyspnea, after being non-complaint with medications for two weeks. 

The patient was hemodynamically stable.  Electrocardiogram (ECG) revealed normal sinus rhythm with no acute ST changes.  Chest x-ray reported no acute cardiopulmonary disease.  The patient was given a dose of intravenous (IV) Lasix and was admitted to telemetry for management of CHF exacerbation.  Brain natriuretic peptide (BNP) was elevated at 5912.  There was no significant elevation in cardiac enzymes.  The patient's outpatient medications were restarted.  The patient improved clinically and was discharged.

No, the proposed treatment was not medically necessary.

The patient presented with an exacerbation of chronic systolic CHF, consistent with fluid overload.  The patient was hemodynamically stable and had normal oxygen levels on room air.  There was no evidence of acute myocardial infarction, acute coronary syndrome, or arrhythmia.  The patient was treated with IV Lasix with clinical improvement and his outpatient medications were resumed.  The patient was subsequently discharged the next day in stable condition for outpatient follow-up.  Given the presentation and course, as well as known diagnosis of CHF, this admission to an acute inpatient setting was not medically necessary, and the management of his acute exacerbation could have been performed in a lower level of care with outpatient follow-up.