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

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a previously healthy woman. She presented to the ED (emergency department)  with the complaint of abdominal pain, nausea, and vomiting of 3-days duration. Vital signs at the time of presentation were normal.  Examination revealed a tender abdomen in the right lower quadrant. The WBC (white blood cell) count was normal at 6.6 K (thousand).  Hemoglobin was normal at 11.5.  Abdominal CT (computed tomography) showed a normal appendix and no acute intra-abdominal or intrapelvic findings.  Surgical consultation was obtained.  The patient was admitted to the hospital.

The patient was initially treated with NPO (nothing by mouth) status, IV (intravenous) fluid and follow up lab data.  The records indicate that the patient left the hospital against medical advice.

The health plan rationale for denial of inpatient care was based on MCG (milliman care guidelines) Criteria 24th ed-Abdominal Pain, Undiagnosed.

No, the Inpatient admission was not medically necessary.

The care and treatment provided during this time could have been rendered with an observation level of care and did not require an inpatient designation.  This lower level of care would have provided for surgical assessment, IV (intravenous) fluid, follow up, labs, and overnight monitoring.

Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored with an observational status.

This patient presented with abdominal pain.  Her evaluation with examination, lab data, and CT (computed tomography) scan identified abdominal tenderness but no obvious indication for acute surgical intervention.  The patient was monitored overnight, but left the hospital against medical advice.  She was clinically stable during the period of monitoring.

This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for clinical assessment and monitoring as was performed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical Adenocarcinoma in Situ

Treatment egg retrieval for fertility preservation codes, 58970 Follicle puncture for oocyte retrieval, any method; 76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation; S0126 Injection, follitropin alfa, 75 IU [internal units]; S0122 Injection, menotropins, 75 IU;82670 Estradiol; total and 84144x2 Progesterone

The insurer denied coverage for egg retrieval for fertility preservation codes, 58970 Follicle puncture for oocyte retrieval, any method; 76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation; S0126 Injection, follitropin alfa, 75 IU; S0122 Injection, menotropins, 75 IU;82670 Estradiol; total and 84144x2 Progesterone

The denial is upheld

The patient has a past medical history of cervical adenocarcinoma in situ requesting coverage for egg retrieval for fertility preservation.  As part of education and informed consent before cancer therapy, health care providers should address the possibility of infertility with patients treated during their reproductive years (or with parents or guardians of children) and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists. Sperm and embryo cryopreservation as well as oocyte cryopreservation are considered standard practice and are widely available. Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner and/or patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries. This patient however is not planning any treatment, at this time. 

The provider stated that egg freezing is necessary because of a diagnosis of anovulation. Anovulation is not an indication for egg preservation. When the patient is ready to conceive and if she fails to, her anovulation can be treated, and multiple options are available for treatment of anovulation: Clomiphene, Letrozle, FSH [follicle-stimulating hormone] and HMG [Human Menopausal Gonadotropins]. Anovulatiuon is not a reason for egg preservation.

The provider also stated that egg freezing is needed because of possible future treatments.  This is not an indication for egg freezing. When and if the patient needs any gonadotoxic treatment that may threaten her future fertility, she could then undergo fertility preservation.

In summary, as of now there is no medical indication for such procedures. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for egg retrieval for fertility preservation codes, 58970 Follicle puncture for oocyte retrieval, any method; 76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation; S0126 Injection, follitropin alfa, 75 IU; S0122 Injection, menotropins, 75 IU;82670 Estradiol; total and 84144x2 Progesterone is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: synovial sarcoma

Treatment: proton beam therapy

The insurer is denied coverage for proton beam therapy

The denial is overturned. 

This female patient has a history of recurrent monophasic synovial sarcoma of the left posterior thigh.

It is an appropriate level of service that can be safely provided, better than a photon plan for protecting critical structures. For these reasons, included from the clinical information provided, the NCCN and ASTRO guidelines, proton beam therapy, for this patient with a synovial sarcoma of the left posterior thigh, now recurrent with an indication for radiation treatment of her recurrent disease is 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 proton beam therapy is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertriglyceridemia, obesity, type II diabetes, and hypertension.
Treatment: Icosapent Ethyl (Vascepa) 1GM Capsules.
The insurer denied the Icosapent Ethyl (Vascepa) 1GM Capsules.
The denial is upheld.

This is a female with hypertriglyceridemia, obesity, type II diabetes, and hypertension. A request for Vascepa is under review.  The prior request was denied as the patient is not taking a statin. The attending physician is appealing this determination as the request is for continuation of therapy. There are no paid claims for Vascepa.

No, the proposed Vascepa is not medically necessary.
The REDUCE-IT trial demonstrated a reduction in cardiovascular events with the use of Vascepa in people living with type II diabetes with elevated triglycerides between 150-499 milligrams per deciliter (mg/dL) [1]. In this trial, patients were on statin therapy and this patient is not on statin therapy. It is unknown if Vascepa is safe and effective in this clinical situation and its use in this clinical situation is not supported by the Vascepa prescribing information. Therefore, no, the proposed Vascepa is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The requested Vascepa was not medically necessary and it was appropriately denied.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history of hyperlipidemia, hypothyroidism, and petit-mal seizures as a child, who presented to the emergency room (ER) with a seizure. The seizure lasted around 5 to 10 minutes. He was given 5 milligrams (mg) of intramuscular (IM) versed in the field.
The patient was admitted for seizure. He was initially not alert, arousable by minor stimulation to obey, answer, and respond. Neurology was consulted and the patient was started on Keppra. He was given vitamin B12 for borderline deficiency. A magnetic resonance imaging (MRI) scan of the brain and electroencephalogram (EEG) was performed.
Initial vitals included a heart rate (HR) at 121, blood pressure (BP) was 167/91, temperature was 97.8, and oxygen saturation was 100% on room air. His labs were normal. The imaging was significant for a computed tomography (CT) scan of the brain, which showed no acute intracranial infarct or hemorrhage. A chest x-ray showed mild patchy atypical appearing left greater than right lower lobe infiltrates and/or atelectasis. The MRI scan of the brain showed multilevel periventricular and subcortical foci of T2 hyperintensity, appearing mildly increased from prior study. While findings may reflect chronic small vessel changes, some periventricular foci appear oriented perpendicular to the ventricular margin, suggesting foci of demyelination. The electroencephalogram (EEG) was abnormal and consistent with a form of primary generalized epilepsy.
At issue is the medical necessity of the inpatient stay.

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

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
According to Galizia and Faulkner on the diagnosis and management of seizures in adults, indications for urgent imaging and/or hospital admission include, indications for urgent brain imaging and/or hospital admission, acute head trauma, new onset focal neurologic deficit, altered mental status persists (behavior or cognition), recurrent events, persistent headache, anticoagulation, a history of immunodeficiency or malignancy, fever, focal seizure (partial seizure), new neurological symptoms prior to the seizure, and patients in whom follow-up cannot be ensured. The patient did not meet any of these indications according to the documentation.
The patient presented with a seizure, his first since childhood. He had no recurrent seizure. He did not have focal neurologic deficits. He was hemodynamically stable and did not have findings on the brain imaging of a CT and MRI scan, that required acute intervention.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial droop. 
Treatment: Inpatient admission. 

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

The patient is a woman. She presented with hypertension, headache, blurry vision, right sided facial numbness and left sided facial droop for 24 hours. 

The patient's temperature was noted to be elevated. Left sided droop was noted. NIHSS (National Institutes of Health stroke scale) score was 3. Other vitals were normal. CXR (chest x-ray) was negative. CT (computed tomography) head was unremarkable. CTA (Computed Tomographic Angiography) of the carotids was unremarkable. Dysphagia screen was negative. 

The patient was admitted to the neurology telemetry unit to evaluate for a transient ischemic attack or stroke. MRI (magnetic resonance imaging) was unremarkable. Impression was that of Bell's Palsy. 

The health plan's prior denial reason is because patient did not have inpatient needs. The patient did not have any abnormalities in heart rate, temperature, breathing rate, oxygen level and blood sugars.  Brain MRI (magnetic resonance imaging) did not show any acute process. Furthermore, notes did not indicate that the patient did not get better after observation level treatment. For these reasons, it was thought that care did not need to be escalated beyond the emergency room or observation level and that follow up could have been done in an outpatient setting. 

No, the Inpatient admission was not medically necessary. 

Emergency room and observation status was appropriate in this patient. Obtaining the appropriate workup to rule out a transient ischemic attack or stroke including MRI (magnetic resonance imaging) of the brain, CTA (Computed Tomographic Angiography) of the carotids, telemetry monitoring, and labs can be done within 24-48 hours, which can be done on an observation status. The patient did not need any rehabilitation services including physical therapy, occupational therapy or speech therapy. Since the workup for a stroke or transient ischemic attack was negative and patient was determined to have Bell's palsy, observation level with a discharge to primary care doctor or clinic was appropriate. Furthmore, the American College of Emergency Physicians provides a Level B Recommendation for the use of rapid diagnostic protocols in evaluation of a stroke or transient ischemic attack. 

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

As stated in the previous answer, all workup to rule out a stroke or transient ischemic attack can be completed in 24-48 hours. If there was a stroke and this required a longer stay with further workup and ancillary services, then the observation level could be switched to an inpatient status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Miller-Fischer syndrome.
Treatment: Continued Inpatient Hospital Admission.
The insurer denied the Continued Inpatient Hospital Admission.
The denial is upheld.

The patient is a male who presented with the complaint of progressive ophthalmoplegia, ataxia, areflexia, dysarthria, dysphagia, and diplopia. He was admitted to the acute inpatient service and diagnosed with  Miller-Fischer variant Guillain-Barre syndrome (GBS).  He was treated with eight days or plasma exchange followed by three days of intravenous immunoglobulin (IVIG). He required tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement.

No, the proposed continued inpatient admission was not medically necessary.
Acute treatment for the patient's underlying condition was completed and his neurological status was stable and improving. He was hemodynamically stable. The patient was participating with physical and occupational therapy. He was established on enteral feeds and was actively weaning from ventilator support. There were no continued complications that required acute inpatient admission. Finally, progress note by the patient's physician states, "awaiting dispo to rehab" further supporting that he was medically stable for discharge.   The patient did not require continued treatment at the inpatient level of care. He could have safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Pharmacy/Prescription Drugs-Synagis.
The insurer denied: Synagis. 
The health plan's determination is upheld in whole. 

The patient is a preterm infant. The patient's primary care provider is requesting Synagis (palivizumab) for monthly administration, stating she is at increased risk of severe disease, hospitalization, and death from respiratory syncytial virus (RSV). No further documentation of her medical history is provided.
The subject under review is the medical necessity for Synagis for this patient.

The health plan's determination is upheld in whole.

Based on the information provided, the requested health service/treatment of Synagis is not medically necessary for this patient.
In the first year of life, palivizumab prophylaxis is recommended for infants born before 29 weeks, 0 days gestation. In the first year of life, palivizumab prophylaxis is also recommended for preterm infants born before 32 weeks, 0 days gestation who have chronic lung disease of prematurity defined as a need for greater than 21% oxygen for at least 28 days after birth, and for certain infants with hemodynamically significant heart disease.
In this case,  there is no documentation of any additional factors that would put the patient at greater risk of severe RSV infection. Synagis has a limited impact for infants born at 29-36 weeks gestation, and in fact in studies of infants 33 to 36 weeks gestation, there were no significant differences by palivizumab administration status.
Therefore, the documentation does not support the medical necessity of Synagis in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis. 
Treatment: Inpatient Hospital Stay. 

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

The patient has a past medical history (PMH) of coronary artery disease (CAD) status/post (s/p) two stents, hypertension (HTN), human immunodeficiency virus (HIV), chronic obstructive pulmonary disease (COPD) and testicular cancer who was admitted with complaints of (c/o) increasing pain and swelling of his left hallux after a splinter. Of note, this was the second presentation for this complaint and after splinter removal and oral antibiotics, he presented the second time after the wound opened up and increased in size. Vital signs were unremarkable. The physical exam was notable for significant left toe swelling, tenderness to palpation (TTP), and erythema spreading to the left medial malleolus and first three toes. Lab work was unremarkable. Imaging studies showed no acute abnormalities, magnetic resonance imaging (MRI) showed no osteomyelitis. The patient was diagnosed with cellulitis and treated with intravenous (IV) antibiotics and cultures. An incision and drainage (I&D) was performed and cultures were negative. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care. 

The hospital stay was medically necessary at an acute inpatient level of care.
This patient presented to the ED with increasing pain and swelling after a previous emergency department (ED) visit and three days of oral antibiotics treatment with an appropriate regimen. The patient experienced increasing erythema spreading of the left medial malleolus and increased pain. This patient was on appropriate therapy with a first-generation cephalosporin with progression of the infection. In addition, there was clinical concern for osteomyelitis and he was placed on broad-spectrum antibiotics while awaiting further radiological and microbiological work-up. Overall, this patient failed outpatient treatment and had progression of his infection and thus could not have been safely treated at a lower level of care. 

Regarding the provided criteria, the patient met the following: Admission is indicated for 1 or more of the following: failure of outpatient treatment indicated by: progression after adequate trial, adequate antibiotic regimen, outpatient IV therapy not appropriate: immediate initiation of intravenous (IV) therapy.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She was hospitalized after fainting. She presented to the ED (emergency department) for evaluation following dizziness and lightheadedness with syncope. Her past medical history is remarkable for hypertension and schizophrenia. 

The patient's vital signs revealed positive orthostasis. She was noted to have generalized stiffness, orofacial dyskinesia and tremors felt to be from her antipsychotic meds. Treatment included IV (intravenous) fluids, Cogentin and psychiatry and cardiology consultations. No arrhythmias or MI (myocardial infarction) were reported. She had a normal echocardiogram. 

The health plan denied coverage of the inpatient admission. This denial is being appealed. 

No, the Inpatient admission was not medically necessary. 

Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. Inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the current guidelines. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, pericardial tamponade, pulmonary embolism, syncope causing injury requiring hospitalization, inpatient admission required rather than observation care because of a significant finding or clinical condition judged too severe or too persistent to be within scope of observation care, such as cardiac arrhythmias of immediate concern, acute coronary syndrome or myocardial Infarction, structural cardiac disorder like severe aortic stenosis or suspected as cause that requires immediate correction, respiratory distress, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding or clinical condition judged not to be within scope of observation care. The care the patient received for uncomplicated syncope is routinely provided safely and effectively at a lower level of hospital care, such as in the ED (emergency department) or Observation setting. 

Therefore, given the above, the Inpatient admission was not medically necessary, based on the submitted information and the current published medical literature evidence-based standards. 

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 

Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient presented to the emergent department (ED) after referral from urgent care center with complaint of right (R) sided chest pain. The patient complained of some back pain the previous day, denied fever, chills, shortness of breath (SOB). The patient has a history of abnormal uterine bleeding for which she was on oral contraceptive pills (OCP) for months.  Vital signs at presentation: Temperature 98.8, heart rate (HR) 68, respiratory rate (RR) 18. BP (blood pressure) 131/78. Oxygen (O2) saturations 99% (percent) on room air. The patient was in no acute stress (NAD). Lungs were clear. Physical exam was essentially unremarkable.  White blood cell (wbc) was 6.7. Hemoglobin (hbg) 13.3. Electrolytes within normal limits (wnl). Chest x-ray (CXR) revealed no acute infiltrates. Electrocardiogram (EKG) no acute changes.  Troponin was Negative. Computed Tomography (CT) Angiogram revealed a possible small right upper lobe pulmonary embolism (PE). Deep Vein Thrombosis (DVT) Study of the lower extremities was negative. 

The patient was admitted to hospital, placed on Telemetry, was treated with intravenous (IV) fluids, Lovenox. Oral contraceptive pills (OCP) were held. The patient was seen by Hematology who recommended to continue Lovenox. The patient was seen by Pulmonary who recommended continuing anticoagulation hold OCP. She was cleared for discharge next day. The patient remained afebrile and Hemodynamically (HD) stable after admission. Myocardial Infarction (MI) had been ruled out. The patient was not hypoxic O2 saturations 98-100%. The patient was tolerating oral intake. 

This patient did not need acute hospitalization. Could have been placed on Observation status while diagnostic testing and treatment were being undertaken. 
Observation can be for up to 48 hours. This patient was overall stable and not hypoxic. She could have been placed under observation and discharged home on PO (oral) meds after a suitable period in observation. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.