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

Diagnosis: High blood pressure
Issue under review: Inpatient admission 
The insurer denied the Inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a male with history of diabetes (recently diagnosed), hypertension, chronic kidney disease, depression, and anxiety. He was sent to the acute care facility from a psychiatric unit (where the patient resided due to depression with suicidal ideations) after a blood pressure of 183/121 was noted.  

The patient was without acute complaints on presentation.  Laboratory indices were notable for a potassium 4.2, bicarbonate 27, BUN (blood urea nitrogen) 14, creatinine 1.3, and hemoglobin 14.7.  The chest x-ray showed no acute process.  The urinalysis and cardiac enzymes were negative.  Nifedipine was administered in the emergency department, with subsequent blood pressure of 165/105.  Oral nifedipine given once daily was continued, with subsequent normalization and the blood pressure.  The creatinine on follow-up was 1.4.

The patient's elevated blood pressure was not accompanied by evidence of hypertensive emergency.  There was no evidence of and organ damage such as acute cerebrovascular accident, acute myocardial ischemia, hypertensive encephalopathy, papilledema, acute heart failure, acute kidney injury (the patient was known to have chronic kidney disease), or acute cerebrovascular accident.  Intravenous antihypertensive agents were not provided.  The blood pressure normalized with only once daily administration of nifedipine.  Renal function remained stable during the hospital stay.  In addition, there was no evidence of diabetic ketoacidosis or nonketotic hyperosmolar state, and an insulin infusion 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.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes 
Treatment:: Janumet.
The insurer denied Janumet.
The denial is Upheld.

This patient is a female diagnosed with type two diabetes mellitus (T2DM). This request is for Janumet. As reported, the patient was having a lot of stomach issues and diarrhea due to being on metformin. She has been on Janumet for seven years.

The dipeptidyl peptidase-four (DPP IV) Inhibitors have similar efficacy. There are no trials showing superiority of one DPP-IV inhibitor over another [1-4]. The American Association of Clinical Endocrinologists consensus statement regarding treatment of patients with type two diabetes is as follows [5, 6]: It recommends the use of metformin followed by the use of a DPP-IV inhibitor or a glucagon-like peptide-one (GLP-1) agonist.  

The formulary alternatives that are proposed by the health plan are Jentadueto and Jentadueto XR. The metformin portion of the formulary alternative compared with the requested medication is no different. The DPP-IV inhibitor portion is not expected to cause gastrointestinal side effects. The patient can try the formulary alternative. The health plan should not cover the proposed treatment as it is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory system /pneumonia 
Treatment: Inpatient hospital  
The insurer denied the acute inpatient hospital stay. 
The denial is Overturned in whole.


The patient in this case  who presented to the emergency department (ED) with complaints of productive cough with yellow sputum as well as fevers with hot flashes and chills that was ongoing for 3 days prior to admission. The patient lives in a shelter and has a history of asthma and blindness due to an injury as a child. The patient has lived in a shelter for the last 2 years and had no sick contacts. The patient  presented with tachycardia (heart rate (HR) 110) and respiratory rate was 18.
The patient lives in shelters and this is a significant risk factor for development of TB infection. Due to this risk, he required hospitalization for infection control in a manner that is not able to be monitored in lower level of care.
 This patient, as documented, lives in a shelter. Shelters are a risk factor for acquisition of pulmonary tuberculosis. This is related to the inherent heterogeneity of individuals who will reside in the area at any given point in time. Tuberculosis, as a disease, is spread via respiratory droplets and, when you live in a shelter, the common areas where people stay tend to be poorly ventilated (in comparison to a negative pressure room) such that droplets become aerosolized and are able to be inhaled by those who are living there. The individuals who go to the shelters will have no idea of the health status of anyone else so it would be impossible to know if they were infected without performing the standardized screening, which is a sputum culture for acid-fast bacteria (AFBs). This requires the patient to produce a sputum sample that must be analyzed by the lab to determine if there is evidence of the bacteria. This sputum sample is taken over 3 days so that a representative sample can be obtained for screening. Based on standard of care, this would require an inpatient level of care as TB is a public health disease with significant ability to cause morbidity if left to run rampant. It is because of this that the patient required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bleed (during pregnancy)
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a G2 P0010 female. She presented to the hospital at 35 weeks six days gestation with bright red bleeding with dark red clots and spontaneous rupture of membranes.  She was known to have a posterior marginal placenta previa.  

Fetal monitoring demonstrated moderate variability and accelerations.  She was admitted for inpatient care.  Irregular contractions were noted.  Betamethasone was administered.  A specific test for SROM (spontaneous rupture of membranes) was obtained which was negative.  The patient stabilized and was discharged home.  

The facility contends that the admission was medically necessary and cites MCG-OBD indications for inpatient care - uterine bleeding with high risk features pregnancy longer than 23 weeks and placenta previa, known or suspected (1 or more needed).  The health plan contends that the admission was not medically necessary because she did not break her bag of waters and had no further bleeding, abnormal monitoring, evidence of labor, rupture of membranes, or bleeding from the afterbirth and cites MCG 23rd edition obstetric and gynecologic care.

Yes, the Inpatient admission was medically necessary.  

Placenta previa is a life-threatening complication for both mother and baby.  The diagnosis of placenta previa confirmed with ultrasound requires close observation when bleeding occurs, because severe bleeding to the point of exsanguination, disseminated intravascular coagulation or dilutional coagulopathy, and fetal hypoxia, intrauterine brain or other injury, and death can occur.  This degree of monitoring cannot be provided at lower than inpatient level of care. Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches and right corneal abrasion 
Treatment: Inpatient stay 
Decision: Denied 

Summary: 
The patient is a female who presented with the complaint of right sided face and orbital pain. She was diagnosed with right corneal abrasion prior to presentation. A CT angiogram showed right MCA (middle cerebral artery) stenosis. CT brain was normal. She was admitted for further evaluation and management of headache. 

The patient presented with right face and eye pain with a known diagnosis of right corneal abrasion. The diagnostic studies, clinical presentation and evaluations did not warrant acute inpatient level of service. The patient could have been safely and effectively treated at a lower level of care. Standard of care guidelines do not support the management of corneal abrasion, eye pain and headache at any acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal/GJ tube replacement
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned the health plan's determination in whole. 

The requested health service/treatment of Inpatient Hospital Stay was medically necessary for this patient. This patient with history of Hypoxic Ischemic Encephalopathy  (HIE), seizures, developmental delay, airway clearance impairment and GJ tube dependence presented with dislodged GJ tube. This patient receives all medications as well as feeds via the  GJ tube. After presentation patient also developed fever that was assumed to be from viral infection. Given  past medical history and complexity of  medical care, admission to inpatient level of care for close monitoring and IVF maintenance would be prudent as this patient is at risk for breakthrough seizures leading to possible status epilepticus or aspiration with respiratory compromise. After anesthesia for the procedure to replace  GJ tube patient  required ventilatory support with weaning and subsequent need for supplemental O2. The pre-op assessment by anesthesia reported that after  previous procedures patient  had to remain intubated. Patient had persisting fever as well as multiple chest x-rays that revealed new findings that were developing during the short stay that required close respiratory monitoring. Patients with complex medical histories and multiple medical issues such as this patient need a higher level of care to monitor their cardiorespiratory status during hospitalization. Given the patient's dependence on the GJ tube for  medications and feeds, expedient replacement of the tube is medically necessary, and the level of care needed as patient waits for it to be replaced as well as monitoring post anesthesia must be provided as an inpatient. The level of care needed to accomplish this for the patient described must be provided as an inpatient given  the  risk for breakthrough seizures leading to possible status epilepticus as well as respiratory compromise and possible respiratory collapse given a  history of airway clearance impairment. The seizure threshold has also been lowered as the patient began having fevers after admission to the hospital. Inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnoses: Orthopedic/ Musculoskeletal
Treatment: Prosthetics
The insurer denied proposed service of prosthetic arm.
The health plan's determination is overturned in whole. The proposed service of prosthetic arm is medically necessary for this patient. 
This patient  per the provider on  has lost all fingers "down to the palm on  dominant right side and down to the first knuckle on  nondominant left side." While a body powered upper extremity prosthesis is typically standard of care for a single upper extremity amputee this is not the case for bilateral upper extremity amputees. This patient does not have the benefit of retraining her non-dominant hand and does not have a sound hand to perform most activities. Instead, as the provider noted, the patient requires assistance with all care including peri care following a bowel movement. Therefore, this prosthesis is not an assistive device but, instead, an essential device. The patient does not even have the ability to form a pincer grip on the non-dominant hand as the provider noted that amputation on non-dominant hand is "down to the first knuckle." A body powered prosthesis requires a harness which in and of itself will be difficult for this patient to don independently while a myoelectric prosthesis will allow for independent donning and doffing. In addition, a myoelectric prosthesis will allow this patient to have unrestricted range of motion of the shoulder and elbow. A myoelectric prosthesis will also allow for increased grip strength and does not require sustained input requiring the user to concentrate on the mechanical use and not the functional task. For all these reasons, a myoelectric upper extremity prosthesis is not only  medically necessary but also standard of care for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the proposed inpatient admission was not medically necessary.

The patient is a male with a history of glioma who presented to the ER following a seizure.  He was taking medications for hepatitis B. 

On arrival to the ER, the patient was alert and oriented with stable vital signs.  He had no focal neurological findings.  He was admitted to the hospital for head/neck computed tomography (CT).  The patient was placed on Keppra.  He also reported chest pain and had an electrocardiogram (EKG) and serial cardiac enzymes performed   His CT scans were negative.  The on-call physician form neuro-oncology stated that seizure can occur post craniotomy.  The patient was monitored for several days and then discharged. 

This patient did not require acute level hospitalization for management of one seizure with full neurological recovery in the setting of a known glioma.  On arrival to the ER, the patient was alert and oriented with stable vital signs.  He had no focal neurological findings.  This could have been managed on an observational status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Coronary artery disease.
Treatment:  PET Scan of heart.
The insurer denied PET Scan of heart.  The health plan's determination is Upheld.

The patient is a female with a past medical history significant for hypertension, obesity, DM (diabetes mellitus), sleep apnea, CML (chronic myelogenous leukemia) in remission, CKD (chronic kidney disease), and mild aortic stenosis.  The patient was diagnosed with CAD (coronary artery disease) with abnormal PET myocardial perfusion scan and was treated medically. 

The patient was hospitalized for dyspnea and suspected diastolic CHF (congestive heart failure) and was treated medically as well, responded to diuresis.  She was seen for cardiology follow-up for exertional dyspnea and was recommended to undergo a stress echocardiogram, which was performed.  Stress echo revealed normal baseline EF with mild aortic stenosis and Grade I diastolic dysfunction.  Stress echo revealed inducible septal and inferior-basal hypokinesis, consistent with CAD. The patient was continued on medical therapy.  A repeat stress PET scan was requested for further ischemic evaluation.

The patient is a female with risk factors for CAD, who was diagnosed with CAD with prior PET scan and again had evidence of stress induced ischemia/wall motion abnormality on stress echo, and was treated with medical therapy for CAD.  There was no evidence of acute coronary syndrome, MI or unstable angina.  Treatment strategies for chronic coronary artery disease management include conservative (medical therapy) or invasive (catheterization) approach, usually guided by acuity of symptoms, severity of angina symptoms and response to medical therapy.  In this patient with chronic CAD, previously diagnosed with non-invasive testing, managed with guideline directed medical therapy, repeat nuclear perfusion imaging would not result in a meaningful change in management, as decision to proceed with cardiac catheterization and possible revascularization would be guided by symptoms in the setting of known CAD.  Therefore, the medical necessity of the requested PET myocardial perfusion scan could not be established in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation 
Treatment: Hospital admission 
The insurer is denied coverage for full hospital admission. 
The denial is upheld. 

The patient was then a female with history of hypertension (HTN) and asthma who presented to the Emergency Department (ED) with complaint of shortness of breath for days. The patient did not respond to nebulizers. The patient had recently been treated with oral (PO) antibiotics for cough. At ED presentation, the patient's vital signs were: temperature 37.1, blood pressure 128/83, respiratory rate 20, heart rate 80, and oxygen (O2) saturation 96 %. On exam, the patient was awake, alert, and in no acute distress. The patient's lung exam revealed some wheezing. The patient was treated with steroids, bronchodilators via nebs. The patient was admitted for asthma exacerbation. As per the History & Physical note, the patient was in no acute distress, and was afebrile and hemodynamically stable. The patient's lungs were noted to be clear; the patient's cardiovascular and abdominal exams were unremarkable. The patient's white blood cell (WBC) count was 9.5 K, and the patient's hemoglobin was14.4. The patient's electrolytes were within normal. The patient's chest x-ray was also within normal limits. The patient's procalcitonin was negative. The patient remained stable after admission, and her clinical status Improved with treatment. The patient was discharged. 

Based on the review of the medical record and the literature, this patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatments were initiated. The patient was afebrile and hemodynamically stable. The patient's white blood cell (WBC) count was normal. The patient was not hypoxic. The patient's chest x-ray revealed no infiltrate or clinical signs of infection. The patient's clinical status improved after initial treatment in the Emergency Department. The patient could have been discharged home after a period of observation on oral medications, such as steroids, antibiotics if clinically indicated and bronchodilators, and with close follow up in outpatient 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 full hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope with hyperglycemia
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

This patient is a male with type 1 diabetes. He presented after a syncopal episode with hyperglycemia. He had fallen down stairs, and the patient reported that he passed out for two hours. 

The patient's CPK (creatine phosphokinase) was 236, glucose 471 mg/dL, anion gap 23, CO2 (carbon dioxide) 19, creatinine 0.8, beta hydroxybutyrate 3.1, urine ketones >80. He was treated with normal saline and intravenous insulin. His physical exam was notable for wrist ecchymosis. His BP (blood pressure) was 110/65, and heart rate 69. He was seen by trauma for tertiary survey. No acute injuries were noted. Inpatient admission is under review.    

This patient presented with mild diabetic ketoacidosis. Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness such as sepsis [1], which is not documented in this case. This patient had a syncopal episode prior to admission, but on presentation, he had normal mental status and had only mildly elevated creatine kinase levels. He had normal renal function. His trauma tertiary survey was unremarkable. He was hemodynamically stable. He responded quickly to intravenous hydration and insulin therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet
Issue under review: Braces and monthly visits

Determination:
The Braces and monthly visits are medically necessary.

The patient is a female child. The request is for orthodontic benefits as well as benefits for monthly follow ups.

The patient has nine millimeters (mm) of horizontal overjet. This means her upper front teeth stick out nine mm from the front of her lower front teeth. This is excessive and subjects the patient's front teeth to trauma over time. The probability of fracturing all or part of these teeth is high due to their excessive prominence. Orthodontic treatment is medically necessary to get these teeth back into their proper position so they are not prone to breaking.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoxemia, SOB, cough
Treatment: Continued inpatient admission
The proposed treatment was not medically necessary.

This is a patient with history of scleroderma, pulmonary hypertension with worsening shortness of breath, cough and fevers who presented to emergency room.  The patient was hypoxic and required high amounts of oxygen. The patient had an elevated brain natriuretic peptide (BNP) and chest x-ray showed pulmonary edema.  The patient was admitted to acute inpatient hospital level of care for the management of congestive heart failure (CHF) exacerbation. The patient was started on intravenous (IV) diuresis, as well as IV antibiotics. 

The patient was admitted with acute on chronic hypoxic respiratory failure due to CHF exacerbation as well as possible pneumonia/bronchitis. The patient was treated with IV antibiotics, IV steroids, IV diuresis as well as high flow oxygen. The patient's condition slowly improved and she was titrated off high dose steroids, high flow fraction of inspired oxygen (Fio2). 

For the dates of service under review, the patient was doing well and was hemodynamically stable. The patient was tolerating oral diet and was working with physical therapy. The patient was back on home oxygen requirements.  The continued acute in-hospital level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

The patient is a male with a history of diabetes. On he presented to the emergency room with postural dizziness and some nausea. The vital signs were normal, and the blood pressure went up when he went from sitting to standing. The physical exam was otherwise normal. The glucose was 232 and the hemoglobin A1c was 9.4%; otherwise the labs were non-contributory. The electrocardiogram (EKG) was negative for acute ischemia. The chest x-ray and head computed tomography (CT) scan were unremarkable. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with aspirin and his usual home medications. The echocardiogram revealed normal systolic function, and the carotid ultrasound was negative. EKG monitoring was uneventful. The patient was discharged.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. 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. 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.