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

Diagnosis: Cardiac/Circulatory problems-Chest Pain
Treatment: Inpatient Hospital Admission
The health plan denied the Inpatient Hospital Admission as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This is a patient with a history of diabetes mellitus type 2, essential hypertension, coronary artery disease, coronary artery bypass graft (CABG), and prior non-ST myocardial infarction, who presented to the emergency room (ER) with worsening substernal chest pain that started while walking the day prior and was relieved with rest. In the ER the patient's cardiac troponin was mildly elevated and due to a high suspicion for acute coronary syndrome (ACS), the patient was taken to the cardiac catheterization laboratory (Cath lab) urgently for coronary angiogram. Coronary angiogram showed a patent vein graft to posterior descending artery (PDA), obtuse marginal, and left internal mammary artery (LIMA) to left anterior descending (LAD). There was a new right posterior lateral artery stenosis believed to be the culprit which required multiple percutaneous transluminal coronary angioplasty (PTCA) and then stent placement. The patient was monitored overnight, and his chest pain resolved. The patient was discharged home on the following day in stable condition.

Inpatient Hospital Admission is medically necessary for this patient.
This patient presented with acute onset of chest pain consistent with unstable angina requiring urgent coronary angiogram needing intervention on a severe stenosis of the right posterior lateral artery needing multiple PTCA and stent placement. It was medically appropriate and necessary for monitoring of this patient under inpatient level of care, given his ACS presentation requiring a stent placement. The patient's     (History, ECG abnormalities, Age, Risk factors present, and Troponin measurement) HEART SCORE was elevated, 7, predictive of increased risk for major adverse cardiac event. According to the HEART SCORE pathway, inpatient admission was medically appropriate and necessary in this case. Furthermore, it is standard of care for hospitalization under inpatient level of care for ACS, as in this case where the patient presented with unstable angina, as recommended by the 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the management of patients with non-ST-elevation acute coronary syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory System-cardiac catheterization.
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is overturned.

The patient is a male who presented to the hospital for cardiac catheterization as part of his evaluation for renal transplantation. His medical history was remarkable for hypertension, end-stage renal disease on hemodialysis, anemia, heart failure, gastroesophageal reflux disease, and a small membranous ventricular septal defect. His blood pressure was 118/80 millimeters of mercury (mmHg) with a heart rate of 70 beats/minute. Pre-procedure his serum potassium level was 6.9 millimoles per liter (mmol/L). Coronary angiography showed normal coronary arteries. During the procedure, the patient had an episode of supraventricular tachycardia that terminated spontaneously. However, post-procedure, the tachycardia recurred. It briefly terminated with adenosine but then re-initiated at a rate in the 110s-120s. The patient remained normotensive. Oral metoprolol was started. His serum potassium was 7.6 mmol/L. This was treated with Kayexalate, dextrose, and insulin. This was repeated once for persistent hyperkalemia. The patient remained in tachycardia. He underwent hemodialysis. The tachycardia terminated during dialysis. The patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is overturned.

Yes, an inpatient hospital admission was medically necessary.
This patient, with end-stage renal disease, developed severe hyperkalemia associated with persistent supraventricular arrhythmia. He was at risk for more serious, potentially lethal ventricular arrhythmias. He required careful and continuous monitoring, repeated pharmacologic treatment and frequent laboratory testing. This warranted an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lacerations (wound care)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. His medical and surgical histories were negative. He presented to an emergency room after playing with a knife while intoxicated.

The patient's vitals were temperature 97.1, pulse 86, blood pressure 129/92, respirations 19, oxygenation 98% room air. Physical examination demonstrated: "multiple lacerations involving the right upper extremity measuring 4x2.5 cm [centimeters] on the medial forearm and 2 cm [centimeters] on the lateral forearm with associated hematoma and superficial abrasion overlying the right eyebrow." All of the wounds were "superficial."

Serum laboratories demonstrated a normal hemoglobin of 12.9 and a normal lactate of 1.5. "CT [computed tomography] angiogram of the right upper extremity showed evidence of a forearm laceration with penetrating injury and possible injury to the cephalic vein at the laceration site. No arterial injury identified. No fracture or dislocation." Duplex ultrasonography of the right upper extremity "showed normal imaging."

The patient was admitted at an acute inpatient level-of-care with lacerations and alcohol intoxication. He received intravenous fluids, antibiotics, tetanus vaccination, and wound care. He was cleared by Psychiatry Consultation for discharge.

The patient was discharged home in good and stable condition with outpatient surgical follow-up and prescriptions for oral analgesics.

No, the Inpatient admission was not medically necessary.
The patient did not require admission at an acute inpatient level-of-care due to the following:

1) He did not have significant co-morbidities.
2) His vitals were stable.
3) He did not demonstrate on-going anemia.
4) He did not demonstrate significant blood loss; serum laboratories demonstrated a normal hemoglobin and normal lactate.
5) He did not have evidence of neurovascular injury.
6) He did not have evidence of orthopedic injury.
7) All of his injuries were "superficial."

All of the provided treatments (intravenous fluids, antibiotics, tetanus vaccination, wound care, Psychiatric evaluation) could have been provided at a lower level-of-care.

Based on his history, presentation, examination, and findings, the patient did not require admission at an acute inpatient level-of-care.  All of the provided treatments could have been provided at an lower level-of-care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Thyroglossal duct cyst.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned, in part. 

The patient is a male. The patient underwent excision of a thyroglossal duct cyst and was admitted post-operatively.

Yes, in part. The Inpatient admission was medically necessary, in part. Specifically, the inpatient admission was medically necessary for the inpatient day 1 only.

There was a laceration to the thyroid cartilage of the larynx during the surgery, which was primarily repaired.  The patient was started on POs (by mouth) on the night of surgery and was tolerating them.  Vital signs were stable and the patient was afebrile.  However, there were problems with pain control, as the mother was declining to give the child the prescribed pain medication.  There was no crepitus or other sign or symptom that there was air extravasation leaking from the laryngeal injury.  With the laryngeal injury and the risk of airway compromise secondary to this, the medical necessity of the inpatient date of service would be confirmed.  With the rest of the inpatient stay, due to difficulty with the mother administering pain medication and no explanation as to why hospital staff was not administering pain medication, the medical necessity of the inpatient days cannot be confirmed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gum disease
Treatment: Lower False Teeth and Extraction on Teeth #24, 25 and 26, Pre-service
The insurer denied the Lower False Teeth and Extraction on Teeth #24, 25 and 26, Pre-service
The denial is overturned. 

Yes, the proposed treatment of extraction of teeth #24, 25, and 26 and lower false teeth (lower partial denture) is medically necessary.
In the circumstance when there is active gum disease present and periodontal therapy is no longer effective due to disease progression, the only other option is to remove these teeth and replace them with a removable prosthesis to restore function and provide some level of aesthetics.

Typically, when periodontal disease progresses to a point that some teeth have been more compromised than others (exhibiting extreme bone loss and inflammation, considerable mobility), it allows these teeth in the mouth to act as an added hazard to the patient because the bacteria which is concentrated around these teeth tend to spread to other teeth and begin to compromise the entire dentition and the patient's systemic health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Other/Rotator Cuff Tear
Treatment: Surgical Services/Rotator Cuff Repair
The health plan denied the requested rotator cuff repair. 
The health plan's determination is overturned.

This is a  male who has been recommended for right shoulder rotator cuff repair and biceps tenodesis. A progress report indicates the patient has been having problems with the right shoulder for some time, but he fell one week prior to presentation and landed on the right side with significantly worsening shoulder pain. The physical examination of the right shoulder revealed significant tenderness to palpation from a particular joint, limited active range of motion, positive drop arm test, and weakness of the supraspinatus infraspinatus. X-rays reveal acromioclavicular joint arthritis, mild glenohumeral joint arthritis, and no acute fracture or osseous abnormality. A magnetic resonance imaging (MRI) was ordered to rule out a rotator cuff tear. 

The health plan's  denial of medical necessity is overturned in whole, as the surgery is medically necessary.

Yes. In addition to the policy criteria being met for the requested rotator cuff repair, as noted in the reference articles from the Journal of Bone and Joint Surgery and the Journal of Shoulder and Elbow Surgery, rotator cuff repair leads to superior outcomes compared to nonoperative treatment for rotator cuff tears. Regarding biceps tenodesis, as noted in the referenced article from Clinics in Sports Medicine, biceps tenodesis is a safe and reproducible technique with a low complication rate for patients with biceps tendinopathy. Based on the provided documentation, the requested health service/treatment of shoulder surgery is medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Immunologic disorder
Pharmacy/prescription drug

Diagnosis: lupus nephritis.
Treatment: Lupkynis.
The insurer denied Lupkynis. 
The health plan's determination is overturned.

The patient is a female with a history of diabetes mellitus (DM) with a history of biopsy proven lupus nephritis (LN) class 5. She has persistent nephritic range proteinuria, despite prednisone taper and max dose Cellcept (3g (grams)/day). She is also on Plaquenil. Steroids are causing her DM to be poorly controlled. The issue in this case is Lupkynis (voclosporin) is being denied by the health plan.

The formulary drug would likely not be as effective as the non-formulary alternative. While benlysta has recently been found to be effective in reducing proteinuria in LN patients, it does so at around week 104. A phase III multicenter trial published in The New England Journal of Medicine (NEJM) randomly assigned 448 patients with biopsy-proven, active class III, IV, or V LN to receive intravenous (IV) belimumab (10 mg/kg) or placebo, in addition to standard therapy. At week 104, the rate of renal response was higher in the belimumab group compared with the placebo group. This highlights that while benlysta is effective in LN patients, it was not until week 104.
This patient is already on maximal doses of cellcept and cannot tolerate any more steroids due to her DM. She needs rapid control of her lupus nephritis and cannot afford to wait until week 104. Moreover, this patient is a women with isolated class V LN, which was not substantially represented in the trial. Lupkynis is medically appropriate for the treatment of this patient's refractory class 5 LN at this time.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Overactive bladder.
Treatment: Formulary Exception for Oxytrol Patch for Overactive Bladder.
The insurer denied coverage for Formulary Exception for Oxytrol Patch for Overactive Bladder.
The denial is overturned. 

This is a male patient who has been recommended to utilize Oxytrol patch.  The patient has multiple sclerosis with overactive bladder.  The patient suffers with urgency and frequency.  He has had a trial of oxybutynin and tolterodine without success.  The medications have not relieved the patient's symptoms of overactive bladder and caused intolerable side effects.  The patient continues to suffer from severe bladder dysfunction with worsening, and therefore for it is recommended that he utilize Oxytrol transdermal patch.

The formulary drugs have been ineffective based on the patient's clinical history. The formulary drug(s) is likely to cause the patient an adverse reaction. The treating physician notes that the patient has had significant side effects (anti-cholinergic) with treatment failure with a variety of frontline approaches.

Oxytrol transdermal patch would be expected to be more effective in this case.  The patient has failed frontline therapy with a number of approaches. Oxytrol transdermal patch has been shown to be effective in reducing symptoms of overactive bladder with reduced anti-cholinergic side effects.

The insurer's denial of coverage for Formulary Exception for Oxytrol Patch for Overactive Bladder is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric and periumbilical abdominal pain.

Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay. 

The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with a one-day history of epigastric and periumbilical abdominal pain.  There was associated nausea and vomiting. The patient's vital signs in the ED were within normal limits.  The patient's ultrasound revealed "gallbladder calculi with mild gallbladder wall thickening and mild pericholecystic fluid." The patient's computed tomography (CT) scan demonstrated the same findings as the ultrasound.  The patient's total bilirubin was within normal limits, but the direct bilirubin was slightly elevated at 0.7.  The patient's alkaline phosphatase, alanine transaminase, and aspartate aminotransferase were all elevated at 321, 370, and 637, respectively.  The patient's white blood cell (WBC) count was also within normal limits.  The result of the patient's magnetic resonance cholangiopancreatography (MRCP) performed due to the elevated liver function tests, was "no choledocholithiasis or biliary ductal dilatation." The patient was taken to the operating room (OR) for a laparoscopic cholecystectomy.  There were no reported complications.  There were no reported postoperative complications.  The patient was discharged within 24-hours after the procedure.  There were no reported complications or indications for a delay in surgical intervention after all imaging studies were completed. 

As per literature review, acute cholecystitis and biliary complaints are a common inpatient diagnosis.  Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions.1 Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay.2,4,5 Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting.3 In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible.5,6

Based on the review of the medical record and literature, laparoscopic cholecystectomy can successfully be performed as an outpatient/ambulatory procedure.  The 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.

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

Diagnosis: colorectal care. 	
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is upheld. 

This female patient has a history of Crohn's disease, ulcerative colitis, alopecia, thyroid cancer, anxiety and depression. She presented at the emergency department (ED) at Mount Sinai South Nassau with complaints of right lower quadrant pain times 2 weeks. She was status post surgeries for ulcerative colitis.  The patient had a computed tomography (CT) as an outpatient, and it showed intussusception and multiple kidney stones. The patient reported that she took Zofran but without any relief. Colorectal Surgery recommended she follow up with a magnetic resonance imaging test this week, but the patient's pain worsened. She was directed to follow up with the ED for further management.  Upon assessment, the patient's abdomen was soft, non-distended, and the right lower quadrant was tender. She received intravenous (IV) fluids, acetaminophen and Xanax in the ED. The patient did not have any oral intake. Imaging studies revealed gallbladder calculi were present. Colorectal Surgery was consulted, and the patient was admitted to colorectal care. The treatment plan included serial abdominal exams and continuing IV fluids, but advancing the patient's diet. The patient also received pain management. A repeat CT scan did not show intussusception. The patient's diet improved, and her pain was managed. The patient's nausea was also controlled with Zofran. She was cleared for discharge with instructions to follow up with Colorectal Surgery.

There was no toxicity, abnormal chemistry, acute abdomen, no sepsis, and no uncontrolled pain to warrant admission an inpatient.  Patients that need hospitalization are those with the following signs and symptoms:  volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as human immunodeficiency virus (HIV) and diabetes (immunocompromised status), recent hospitalization or antibiotics, pregnancy, or weight loss.  There was no fever or severe abdominal pain requiring hospital admission rather than ambulatory setting such as observation. Lab data showed no electrolyte discrepancy, acid/base derangement, or renal impairment that needed acute hospital inpatient admission status.  Hydration, IV pain medications, and monitoring in ambulatory/outpatient setting would have been appropriate for this patient and would not have jeopardized her well-being.  The denial for acute admission for hospital stay is upheld based on literature. This patient could have been given the same treatment (hydration, endoscopy, radiological studies, etc.) in "Observation/Outpatient" status.   

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

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

Diagnosis: appendicitis

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient with no significant past medical history. The patient presented to the Emergency room (ER) with complaints of 6 out of 10, abdominal pain, nausea, and vomiting for 2 days. In the ER, the patient was afebrile and nontoxic appearing. The patient's white blood cell (WBC) count was 13.4. The remainder of the patient's labs was within normal limits (WNL). The patient's abdominal ultrasound and computed tomography (CT) scan of the abdomen revealed findings that were consistent with acute appendicitis. The patient was started on pain management and received one dose of perioperative antibiotics. The patient was kept on nothing by mouth (NPO) status. The patient was admitted with right lower quadrant (RLQ) abdominal pain. The patient had a laparoscopic appendectomy and tolerated the procedure well. The care plan included administering 400 milligrams (mg) of oral acetaminophen every 6 hours (Q6H) as needed (PRN) for mild pain, administering 2 mg of intramuscular morphine Q6H PRN for severe pain, and administering 4 mg of intravenous (IV) ondansetron Q6H PRN for nausea. On postoperative day #1, the patient's diet was advanced to a regular diet. The patient was able to tolerate the diet without nausea. The patient's vital signs and labs were WNL. The patient's pain was well controlled with oral pain medication. The patient was ambulating independently. The patient was discharged after a period of stability.     

Based upon the MCG Health Inpatient and Surgical Care 25th Edition Appendectomy, without Abscess or Peritonitis, by Laparoscopy ORG: S-175 (ISC), optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; successfully uncomplicated lap appendectomy; no evidence of postoperative or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet. Based upon the records provided, the patient reached these milestones, and could have been discharged following observation within a 23-hour observation period. Furthermore, according to the MCG, the goal length of stay is ambulatory. The patient did not have any comorbidity that warranted inpatient admission.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.