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

Diagnosis: Acute Coronary Syndrome, Pneumonia
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld.

This patient is a male with a history of coronary artery disease, status post non ST elevation myocardial infarction (NSTEMI), congestive heart failure, atrial fibrillation, cocaine abuse, valvular disease, status post valve replacement. The patient was brought to the hospital by Emergency Medical Services (EMS) with complaints of chest pain, productive cough with yellow green sputum, and shortness of breath; the patient received aspirin and nitroglycerin spray by EMS. His presenting vital signs in the Emergency Department (ED) were: temperature 100.6F, blood pressure 101/49, heart rate 91, respiratory rate 20, and an oxygen saturation of 95%. A physical examination was performed that revealed his lungs were clear, cardiovascular system (CVS) heart sounds S1 S2 were normal, his abdomen was soft, and there was no peripheral edema. Laboratory work up was performed including troponin level and lactate level all with normal results. The Brain Natriuretic Peptide (BNP) was elevated to 2490. A chest x-ray revealed cardiomegaly, but no congestive heart failure. A urine toxicology screen was positive for cocaine and cannabinoids. A urinalysis was suggestive of a urinary tract infection and an influenza screen was negative. A computed tomography of the chest revealed possible atelectasis/small infiltrate in the left lung base. He was admitted to the hospital with questionable pneumonia, urinary tact infection, and congestive heart failure. His medical management included intravenous (IV) fluid bolus, and IV antibiotics. The patient was medically stable and discharged home.
This patient did not need acute hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. The patient had been ruled out for a myocardial infarction. He was afebrile and hemodynamically stable after admission. The patient was awake and alert and the WBC count was normal, as was the BUN/ Creatinine. The patient was tolerating oral intake and there was no overt congestive heart failure. The CURB 65 score was Zero. The patient was stable for discharge home on oral antibiotics and other maintenance medications after a period in observation with close follow-up in the outpatient setting.
The prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.
Based on the above, the medical necessity for the inpatient admission is not substantiated. Please note that the medical record indicates that the patient was discharged. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial was overturned. 

Yes, the proposed treatment is "medically necessary".

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, coronary artery disease (CAD), status post (s/p) recent anterior myocardial infarct (MI), complicated by ventricular fibrillation arrest, ischemic cardiomyopathy, s/p proximal left anterior descending (LAD) stent.  The patient presented to the ER with complaints of new onset left-sided chest pain, dyspnea and diaphoresis. 

The patient was hemodynamically stable. The initial cardiac troponin was negative. The electrocardiogram (ECG) revealed anterior T-wave inversion, consistent with ischemia. The patient was admitted for suspected acute coronary syndrome (ACS) / unstable angina. The patient was admitted to telemetry. He was seen in consultation by cardiology and a cardiac catheterization was recommended. The patient decided to sigh himself out against medical advice and left the hospital.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD, as well as a known history of coronary artery disease, including a recent MI, requiring percutaneous revascularization, as well as ischemic cardiomyopathy. The ECG was unrevealing for ACS, but was abnormal, with findings suggestive of ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended. Given the presentation, as well as clinical suspicion for an acute coronary syndrome/unstable angina, the patient would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Back Pain, Leg Pain.
Treatment:  Inpatient hospitalization.
The insurer is denied coverage for the inpatient hospitalization.  The denial is overturned. 

The patient is a female with a medical history of hypertension, diabetes mellitus, osteoporosis, and arthritis.  She presented to the Emergency Department (ED) with complaints of chronic back and leg pain.  Her presenting vital signs were: temperature of 98.2.7F, blood pressure of 104/67, pulse of 79, respiratory rate of 24, and an oxygen saturation of 98%.  Laboratory work up was performed with results that included a white blood cell (WBC) count of 15.1, a hemoglobin of 9.9, a hematocrit of 31.2, a creatinine of 0.79, a sodium of 129, an albumin of 3.2, a glucose of 121, and a C-reactive protein (CRP) of 19.  The patient was admitted to the hospital for back and leg pain.  A CT scan revealed metastatic lymphadenopathy, bone abnormalities consistent with osteoblastic metastases, and a compression fracture.  The patient was given intravenous fluids and pain management.  Infectious Diseases consulted for a possible urinary tract infection.  Doppler ultrasound was negative for deep vein thrombosis.  She was discharged to continue management as an outpatient.

According to the documentation, the patient presented with chronic pain, significant weight loss, and failure to thrive due to undiagnosed metastatic cancer.  She had multiple laboratory abnormalities including an elevated WBC, anemia, hyponatremia (129), and low albumin.  She had elevated temperatures as well.  A CT scan revealed findings consistent with metastatic carcinoma.  Based on these abnormalities in a high-risk patient with failure to thrive, hospital admission was medically warranted for intravenous fluids, pain management, and urgent need for diagnosis.

The prior determination of denial of acute level of care has been reversed.  The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for the acute inpatient hospitalization is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizure-like activity.
Treatment:  Inpatient admission.

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

No, the acute inpatient admission was not medically necessary.

The patient presented to the emergency ward with the complaint of possible seizure.  At presentation his neurological examination was normal. 

The patient had a possible seizure and was at baseline neurological function at presentation.  He required MRI and EEG to determine appropriate need for anticonvulsant treatment.  This could have been safely and effectively provided at a lower level of care.  The acute inpatient admission was not necessary to complete the required treatment, diagnostic studies or monitoring.
Appeal type: Medical necessity
Decision: Upheld

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

No, the Inpatient admission was not medically necessary in this case.

The patient is an otherwise healthy man.  He walked into the ED and was admitted to the hospital following a fall from a ladder.  He presented to the ED following this accident with complaint of left chest wall pain.  

The patient's GCS (Glasgow coma scale) was 15 at the time of ED evaluation.  His blood pressure in the ED was 161/81 mmHg with a pulse of 82.  The hemoglobin level was 13.8.  Imaging (CT scan) showed fractures of the left 9-10th ribs with no associated pneumothorax or hemothorax.  There was also some fluid around the spleen and left kidney on CT.  He also reported an episode of hematuria when he first arrived in the ED.  This resolved without subsequent hematuria.  

The patient remained stable over the course of observation.  He was treated with hospital admission, pulmonary toilet, incentive spirometry and pain control.  The hemoglobin value remained stable throughout the period of monitoring.  The patient had pain control with oral medications.  He was transferred to the regular hospital floor from the ICU (intensive care unit), where he was initially admitted.  Urology consultation was obtained.  The patient was discharged from the hospital.

Inpatient care was not medically necessary per medical standards for this patient.  The care and treatment provided could have safely and reasonably been administered with an observational level of care.  The patient was clinically stable with normal vital signs, was without respiratory compromise, and remained stable throughout period of monitoring.  An observational level of care would have permitted overnight monitoring, follow up examination, lab assessment, provision of IV fluid and pain medications for this patient.

Inpatient admission may be indicated in the setting of rib fractures for hemodynamic instability, three or more rib fractures, flail chest, acute respiratory failure, pain management, associated injury, infection, hypoxemia, tachypnea, immediate surgery needed or other condition.  While this patient did have two rib fractures and left renal contusion, he was clinically stable, and no surgical intervention was anticipated for this patient.  Pain management was with oral narcotic medications (oxycodone).  Pain management that required parenteral analgesia, clinical instability, or respiratory compromise were not present.  

The submitted medical records do not support the need for an inpatient designation for this patient.  There was no clinical evidence for an ongoing health condition that required an inpatient designation, no evidence for neurologic or vascular compromise, no evidence for wound or other infection. Pain was managed, diet was tolerated, and vital signs were stable throughout the period of monitoring.  Inpatient level of care was not medically necessary based on the submitted clinical data.  His condition met criteria for an observation status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient admission.

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

No, the inpatient admission is not "medically necessary".

The patient is a female with a past medical history significant for HTN (hypertension), asthma, chronic alcohol abuse (last drink 1 week prior to admission), cocaine and benzodiazepine abuse, who presented to the ER complaining of central, non-exertional chest pain of one week duration, as well as requesting detoxification.  The patient was hemodynamically stable.  Her cardiac troponin was negative.  ECG revealed normal sinus rhythm with no acute ischemic changes.  Chest X-ray was unremarkable.  Her potassium and magnesium were low and were supplemented.  The patient was admitted to telemetry floor to rule out ACS (acute coronary syndrome).  Echocardiogram was obtained and revealed normal LV (left ventricular) systolic function with EF (ejection fraction) 60-65%.  Nuclear stress test was negative for ischemia.  CT head was negative.  She was discharged with recommendations for outpatient follow-up.

This patient presented for evaluation of chest pain.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test.  Ischemia was ruled out by stress testing.  There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  There was no evidence of acute withdrawal.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis, Deep Vein Thrombus
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.

This is a male patient with medical history ofhypertension, hyperlipidemia, congestive heart failure (CHF), chronic lymphocytic lymphoma (CLL), seizure disorder, renal insufficiency. He presented to the Emergency Department (ED) with complaints of left thigh swelling. The patient's vital signs on presentation included: temperature 98.5 F, blood pressure 101/65, pulse 91, respiratory rate 26, and oxygen saturation 96% on room air. The patient's laboratory results included the following: white blood cell (WBC) count 16.1, hemoglobin 10.5, hematocrit 33.8, and creatinine-2.4. The patient was admitted and started on intravenous (IV) antibiotics (i.e. Zosyn) for possible cellulitis and Lovenox for possible deep vein thrombosis (DVT) of left lower leg. The patient's lower extremity Doppler revealed a non-occlusive thrombus with the popliteal and posterior tibial veins. Nephrology evaluated the patient for chronic granulomatous interstitial nephritis for which the patient was taking prednisone as an outpatient. Infectious Disease was consulted for the patient's "multiple scabs" to the left knee due to a previous injury.  The patient remained afebrile, hemodynamically stable, and was discharged on oral antibiotics (i.e. Keflex and doxycycline) to continue management as an outpatient.

Based on the review of the medical record, the patient presented with left leg swelling after self-discontinuation of his anticoagulation medications for a dental procedure.  Otherwise, the patient was afebrile and hemodynamically stable.  Although the patient had laboratory abnormalities, these were chronic findings due to his underlying medical issues including elevated creatinine due to granulomatous interstitial nephritis and leukocytosis due to steroid (prednisone) taper.  The patient did not have any clinical evidence for a disseminated infection. The patient's Doppler of lower extremity essentially showed a thrombophlebitis.  Based on the above findings, the patient met criteria for observation level of care.  Inpatient admission was not medically necessary.

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

The carrier's denial of coverage for the acute inpatient stay should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crown restorations

Treatment: Crowns for teeth #4 and 5

The insurer denied coverage for crowns for teeth #4 and 5. The denial is reversed.

The patient is male with a history of diabetes. This patient presented to the dental office for a dental evaluation. X-rays were taken. The treating dentist recommended a retreatment of a root canal, post and core for tooth #6, and crowns for teeth #4, 5, and 6.

Upon review of the submitted documentation which includes copies of full mouth series radiographs, comprehensive dental treatment notes as well as insurer correspondence, it appears that the patient presented for comprehensive dental treatment and failing preexisting crown restorations on teeth #4 and #5.  There is radiographic evidence of open margins.  Based on these clinical findings the attending recommended replacement of the full coverage crowns on these teeth and their use as abutment teeth for support of a partial denture.  

Based on the review of the documentation, the preexisting full coverage crowns restorations placed on these teeth appear to be failing.  The margins are open and there is a significant risk of loss of remainder of the cusp/restoration on both these teeth.  Radiographically, there appears to be possible recurrent caries under the restorations.  Given this clinical circumstance, replacement of full coverage crowns is indicated and is a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice.  As such these services which are also a covered service for this individual would be deemed medically necessary.

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 crowns for teeth #4 and 5 should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper extremity weakness; Aphasia
Issue under review: Inpatient admission
The health plan denied Inpatient admission.

Determination:
The health plan's denial is upheld.

The patient is a adult man with a history of HTN (hypertension) and polysubstance abuse. He presented with two days of left UE (upper extremity) weakness and aphasia.  He has a history of ED visits for alcohol intoxication.  

The patient's VS (vital signs) were as follows:  98.4  74  18  115/66  98%.  His exam was remarkable for bilateral LE (lower extremity) erythema; 3/5 weakness on right wrist extension; sensation intact; passed dysphagia screening.  

The patient's labs were as follows:  WBC (white blood count) 5.3  H/H (hemoglobin/hematocrit) 12.4/38  Plt (platelets) 195  Na (sodium) 140  K (potassium) 3.9  BUN/Cr (blood urea nitrogen/creatinine) 80/.43  EtOH (alcohol) 333.  His CIWA (clinical institute withdrawal assessment) score was 18.  CXR (chest x-ray) revealed pulmonary vascular congestion.  Head CT revealed NAD (no active disease).  EKG (electrocardiogram) revealed NSR (normal sinus rhythm).  

The patient was admitted with impending alcohol withdrawal and rule out CVA (cerebrovascular accident). The plan of care included MRI, carotid dopplers, and CIWA protocol.  

The following day, the patient's vital signs were stable.  His CIWA was 5.  His UA (urinalysis) was positive for cocaine.  

The day after, the patient signed out AMA (against medical advice).  

This patient was admitted after having presented with alcohol intoxication and impending withdrawal.  The patient was hemodynamically stable.  CIWA was 18.  The patient did not have fever.  He did not have tachycardia.  He did not have vomiting.  He did not have gross tremor.  Labs were remarkable for elevated alcohol.  The patient was admitted with plan for CIWA protocol.  The patient rapidly improved.  The day after admission, CIWA was 5.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  

The patient did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache and neck pain

Treatment: Acute inpatient hospital stay

The insurer denied coverage for acute inpatient hospital stay. The denial is reversed.

This patient is a female with a past medical history of cerebrovascular accident (CVA) with left-sided residual, migraines, depression, anxiety, and hyperlipidemia.  The patient was brought in by the Emergency Medical Services (EMS) after the patient fell to the ground after helping a family member with a diaper change.  The patient was unsure if she was dizzy prior to the fall.  Per EMS, the patient was pouring water on herself when they arrived.  The patient admitted to headache and neck pain and mild discomfort with no radiation of pain. 

In the Emergency Room (ER), the patient's blood pressure was 126/94, pulse was 138, respirations were 24, and temperature was 97.6 F.  The ER triage nurse notes indicated that the patient was awake with eyes open and blinking but was nonverbal to triage questions.  The patient was unable to follow commands.  Once responsive, the patient complained of a headache, chest pain, and neck pain.  The patient's National Institutes of Health (NIH) stroke scale (NIHSS) was 2.  Neurology was consulted.  The patient was treated with intravenous fluids, steroids, and acetaminophen.  The patient had an anaphylactic reaction to iodine which was used prior to a catheterization for urine.  The patient was treated with Benadryl, epinephrine and Pepcid for post-reaction treatment.  The patient was admitted to the Telemetry unit. The patient underwent computed tomography (CT) scan of the head which revealed no acute intracranial abnormality. 

Based on the review of the medical record, the inpatient hospital stay was medically necessary.  The patient experienced an alteration in consciousness which at the time of admission was of unclear etiology.  There was a concern for possible hemiplegic migraines, transient ischemic attack (TIA), and the need to rule out stroke. Because there are a variety of conditions that can cause an alteration in the level of consciousness, many of which can be life-threatening, it was appropriate for the patient to be admitted for additional work up. In addition, an NIH stroke scale of 2 is consistent with a minor stroke.  

 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 acute inpatient hospital stay is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Neurosyphilis.
Issue under review:  Inpatient admission.

The health plan denied Inpatient admission.  The health plan's denial is overturned.

The patient is an adult male whose inpatient admission is under review.  The patient has a history of HBV (hepatitis B virus) and syphilis.  He was referred secondary to bilateral macular edema thought to be because of neurosyphilis (+ RPR (rapid plasma regain), + T. pallidum antibodies)

The patient's vitals were as follows: 1) T (temperature) - 98.3, 2) P (pulse) - 90, 3) RR (respiration rate) -16, and 4) BP (blood pressure) -138/87.  One general examination, the patient was NAD (no acute distress).  Examination of his chest, CVS (cardiovascular system), and abdomen were normal.

The patient was admitted for neurosyphilis.  He had an LP (lumbar puncture), which verified this (high WBCs [white blood counts]).  He was started on IV (intravenous) penicillin, PICC (peripherally inserted central catheter) was placed, and arrangements made to finish course of IV penicillin at home.

The reasons given for denial by the insurance company are not applicable in this situation, as the patient's primary problem is neurosyphilis, which has known complications (dementia, stroke, disturbed gait, blindness), and which is treated promptly with IV penicillin for 14 days (1).  Standard of care is to admit, complete work-up, start IV therapy and continue at home, as was done in this case.  Failure to do so could have led to permanent eye damage, or permanent neurological damage.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe asthma
Treatment: Perforomist
The insurer denied the Perforomist.
The denial is upheld.

The proposed treatment with Perforomist is not medically necessary.

The patient is a female with asthma; she was prescribed Perforomist nebulization treatment.

Perforomist is for use only in people with chronic obstructive pulmonary disease (COPD) and should not be used to treat asthma. Perforomist is to be used in combination with inhaled corticosteroids in asthma.  The clinical documentation does not report that the patient has COPD or that Perforomist will be used in combination with inhaled corticosteroids. It is not medically necessary.