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

Diagnosis: Sore throat, dysphagia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary. 

The patient is a female who presented with sore throat for four days, as well as dysphagia.  Outpatient therapy included Augmentin.  In the emergency department vital signs were T (temperature) 98.7, HR (heart rate) 90, RR (respiratory rate) 18, BP (blood pressure) 148/85, spO2 (oxygenation) 98% on room air.  A CT was performed without evidence of abscess but with "Phlegmonous change" in the parapharyngeal space.  The patient was noted to have peritonsillar swelling.  The patient was treated with antibiotic and steroid and the patient showed improvement.  The patient was discharged on hospital day number one on regular diet for outpatient followup.

The patient had no active intervention. The patient could have been managed at lower level of care acuity than acute inpatient. The patient was discharged on the day after admission with steroid and antibiotic therapy.  The patient did not have an abscess but rather peritonsillar cellulitis.  Even with peritonsillar abscess, after drainage in the acute care setting, most patients are discharged as outpatients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis, Renal Stone .
Treatment: Inpatient admission.

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

This is a male patient with a medical history of elevated lipids, benign prostatic hypertrophy, gastroesophageal reflux disease, obesity, kidney stones, nasal surgery, and tobacco use. He presented to the emergency department with complaints of right flank pain and painful urination. Physical examination showed left costovertebral angle (CVA), Urinalysis positive for blood and protein. Computerized tomography (CT) scan revealed 9mm left ureterovesicular junction (UUJ) stone with moderate left hydronephrosis. Urology was consulted. The patient was admitted with renal stone/hydronephrosis. Foley catheter was impacted. The patient was given intravenous (IV) fluids and IV antibiotics. The patient underwent a cystoscopy for a left ureteroscopy (URS), laser lithotripsy, left ureteral stent insertion. The patient tolerated procedure well without complication. He was medically stable and he recovered was discharged to home with outpatient follow-up. 

The insurer noted the admitting diagnosis-kidney stones, pain. They noted there were no unstable vital signs, worsening of kidney function. They also indicated there were no notes that the patient did not get better after observation care. The appeal on behalf of the hospital is noted and read in detail. 

Per MCG Health (23rd) Renal Colic and Kidney Stones, patient fails to meet clinical indications for admission to inpatient care. There include hemodynamic instability, acute renal failure, bilateral obstruction. In addition, per MCG Health (23rd) Urologic Surgery or Procedure GRG, patient is noted to have met the general recovery course discharge parameters in 24 hours post procedure. As per the guideline, this procedure is usually designated for the Ambulatory Surgery setting. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. The inpatient admission was not medically necessary. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive Urgency.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This patient with a history of hypertension, hyperlipidemia, diabetes, obesity, paroxysmal atrial fibrillation and asthma presented to the emergency department complaining of two days of constant, sharp, left-sided chest pain. She had been seen in a different emergency department (ED) the day prior and had been discharged after observation. Her blood pressure at the time of discharge was 170/100 millimeters of mercury (mmHg). She was concerned that this was too high and presented to the second ED. Her blood pressure was 192/113 mmHg with a heart rate of 83 beats/minute. Her respiratory rate was 23/minute. Her room air oxygen saturation was 100%. Her physical exam was unremarkable. An electrocardiogram showed no acute changes. A chest x-ray was unremarkable. A chest computed tomography (CT) angiogram showed no evidence of a pulmonary embolism. The patient was treated with intravenous hydralazine. She complained of a headache. A head CT scan showed no acute pathology. She complained of palpitations; no arrhythmias were documented. She was admitted to the hospital for management of hypertensive urgency. Over the next 48 hours, her oral antihypertensive medication regimen was adjusted. The medical necessity of an inpatient admission is under review.
An inpatient stay was not medically necessary. This patient presented with atypical chest pain and hypertension. There was no evidence of acute myocardial ischemia and it does not appear as if there was significant concern for acute coronary syndrome (ACS) as no treatment for ACS was instituted. While the patient was markedly hypertensive upon presentation, there was no evidence of end-organ damage or decompensated heart failure and she did not require continuous infusion and titration of intravenous antihypertensive medication. Based on the records provided, an inpatient level of care was not medically necessary for blood pressure management. There is no evidence that rapid lowering of blood pressure in patients with severe hypertension and no end organ damage is of benefit and it can be harmful. Outpatient titration of antihypertensive medications with lowering of blood pressure to goal over a period of weeks has been shown to be both safe and effective.
Given the patient's chest pain, it was reasonable to monitor her until her chest pain resolved and acute coronary syndrome could be ruled out. However, this did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal stenosis, dizziness.
Treatment: Consumer directed CDPAP 24 hours per day - Live-In per diem - seven days per week.
The insurer denied the Consumer directed CDPAP 24 hours per day - Live-In per diem - seven days per week.
The denial is upheld. 

The patient is a female with a history of T12 compression fracture and associated chronic low back pain. Due to impairments related to these conditions, she requires assistance for completion of the majority of his/her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in Personal Assistance Services from nine hours per day, seven days per week, to 24 hours per day, live-in per diem, seven days per week, to offer increased ADL support.

No, the proposed treatment of an increase in Personal Assistance Services from nine to 24 hours/week is not deemed medically necessary. 

An in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of nine hours per day, seven days per week, Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of an increase in Personal Assistance Services from nine hours per day, seven days per week, to 24 hours per day, seven days per week, live-in per diem, is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

Diagnosis: Seizure
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with a past medical history significant for a brain tumor, depression, bipolar disorder, and seizure disorder who presented to the emergency department with complaints of possible seizure, passing out, and back pain. Reportedly, the patient remained unconscious for 5 minutes. According to the history and physical (H&P), the patient lost control of her bladder and urinated during this episode.

The inpatient hospital stay was not medically necessary for this patient. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Even though the patient had a brain disorder, this condition was rather chronic and was described as encephalomalacia. There was no evidence that the patient had a brain tumor, hydrocephalus, or any acute infection, the conditions described in the criteria as the reason for admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital
Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a woman with a history of fibromyalgia, asthma, degenerative joint disease, hyperlipidemia, anxiety, rheumatic fever and Raynaud's syndrome who was admitted to the hospital.  She presented with a chief complaint of midsternal chest pain, palpitations and fatigue. She denied that it was related to exertion. She also reported episodes of shortness of breath, and she has been referred to the emergency department by her primary care doctor. 

The inpatient stay was not medically necessary. The reason is that the patient did not have medical acuity consistent with inpatient hospital care. She was low risk for acute coronary syndrome because she had negative cardiac enzymes and an unremarkable EKG. Other acute causes of chest pain were also ruled out at the time of her presentation, and her symptoms of palpitations and lightheadedness resolved on the first day of admission. Overall, her care could have safely and effectively been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth.
Treatment: D7230 - Extraction of impacted tooth with some bone, Tooth 1.
The insurer denied the D7230 - Extraction of impacted tooth with some bone, Tooth 1. 
The denial is overturned. 

The patient is a female with impacted #1 & #16 that are mildly asymptomatic. Tooth #16 was approved for removal, #1 was denied. The examination stated that these teeth were not visible, and the radiograph showed that they were mildly symptomatic.

Yes, the D7230 - Extraction of impacted tooth with some bone, Tooth 1 is medically necessary.

In view of the primary aim of preventing health problems, patients would benefit markedly from elective preventive removal of third molars. Preventive removal is defined as removal of a symptomless third molar before the development of anticipated problems. Preventive removal of mandibular third molars is recommended in four situations to prevent injury of the inferior alveolar nerve, pericoronitis, postoperative bone defects, and caries (Table 1):

1)	If the mandibular third molar is developing in a position in which the root of the tooth and the mandibular canal are superimposed on the radiograph and there is insufficient space for the tooth to erupt or if the direction of eruption is unfavorable, then removal of the tooth is recommended before the growth of the root end is complete to prevent injury to the inferior alveolar nerve.

2)	Acute pericoronitis in 20- to 25-year-old patients can be prevented by electively removing the partially erupted third molars in a vertical and distoangular position and close to the occlusal surface. The patient also can prevent the development of pericoronitis by improving oral hygiene.

3)	Postoperative bone defects of partially erupted mandibular third molars that are in a horizontal position or deeply inclined forward can be prevented by removal before 25 years of age.

4)	Because partially erupted third molars increase the amount of salivary bacteria that cause caries and visible plaque in neighboring teeth, the removal of partially erupted third molars considerably decreases visible plaque throughout the dentition, the amount of bacteria causing periodontal infection in neighboring teeth, and the amount of salivary bacteria causing caries.

Tooth #1 is mildly symptomatic in this case, and the tooth is indicated for removal. The tooth is currently not visible. If it does not erupt, there is the chance of pathology development. If it does erupt, it will not have an opposing tooth and it can surpra-erupt. This would be difficult to maintain good hygiene and increase the chance of caries or periodontal disease. Preventive removal of impacted wisdom teeth at a young age is justified because retained third molars are at high risk of developing various pathologies. In addition, at older ages extraction of these teeth becomes more complex, with an increased rate of complication due to deteriorated systemic physiologic conditions and changes in bone physiology.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female with past medical history of diabetes mellitus and polysubstance use who presented to the emergency department with nausea and vomiting in the setting of having missed insulin doses.
On presentation, she was afebrile with blood pressure 107/60, heart rate 100, respiratory rate 18, and with oxygen saturation of 96% on room air. Exam otherwise noted no clear abnormalities. Labs resulted with white blood cell (WBC) count 7.5, hemoglobin (HGB) 12.1, platelets 261, sodium 125 (corrected to 136), potassium 5.3, blood urea nitrogen (BUN) 16.9, creatinine 1.2, glucose 798, beta-hydroxybutyrate 20.3, lactic acid 5.3 then 2.3, anion gap normal at 10, and with venous blood gas (VBG) noting pH of 7.33 with bicarbonate of 25.3. Urinalysis showed glucosuria and trace ketones. The patient was started on 3 liters of intravenous (IV) fluid and an IV insulin infusion in the emergency department with subsequent over correction of glucose to 63 and decrease in beta-hydroxybutyrate to 1.3. She was subsequently admitted with concerns for hyperglycemia without diabetic ketoacidosis and with plans for IV fluids, initiation of subcutaneous insulin, follow up basic metabolic panel every 4 hours, and watch for alcohol withdrawal.
The patient was hemodynamically stable without fever, hypotension, tachycardia, or tachypnea. She endorsed no nausea, vomiting, or other complaints, and exam was normal. Glucose levels ranged from 63-245 with the rest of her labs unremarkable. The plan was to continue subcutaneous insulin and consult endocrinology. The patient remained hemodynamically stable. She had no complaints and was not noted to be in withdrawal. Glucose levels were in the range of 67-292 and glycated hemoglobin (HbA1c) was 10.2% with other labs unremarkable. She was seen by endocrinology with recommendations made for Levemir 50 units twice daily (bid) and short-acting sliding scale. The patient was discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

This is a patient who presented with nausea, vomiting, and hyperglycemia with notes indicating no concern for diabetic ketoacidosis in the setting of having missed her insulin doses. She was hemodynamically stable on presentation without evidence of associated infection or other acute process contributing to hyperglycemia aside from having missed insulin doses and was started on subcutaneous insulin immediately after emergency room treatment without ongoing requiring for insulin drip. She responded very quickly to therapies with no development of anion gap acidosis and without further symptoms. In the absence of diabetic ketoacidosis, hemodynamic instability, infection or other process contributing to hyperglycemia requiring hospital level care, this patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman with a diagnosis of endometrial hyperplasia who underwent a Laparoscopic supracervical hysterectomy and bilateral salpingo-oophorectomy. The patient is morbidly obese. EBL (estimated blood loss) was 100 cc. Post-operatively, the patient was admitted. Her post-operative course was uneventful. She was discharged home.

No, the proposed inpatient admission was not medically necessary. 

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary. According to the standard of care, inpatient stay may be needed for:

1)  Surgical complications (bladder ureter or bowel injury or hemorrhage)
2)  Conversion to abdominal surgery
3)  Wound complications
4)  Comorbidities

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Postoperatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that a Laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay, if required. Note also that the patient underwent a supracervical hysterectomy and more aggressive procedures like a total hysterectomy also do not require admission.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/gastrointestinal
Inpatient hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a past medical history significant for anxiety, depression, hypertension, and gastroesophageal reflux disease (GERD) who presented to the emergency department with complaints of epigastric discomfort. The patient stated that usually, he drank half-gallon of hard liquor daily. His last drink was on the date of admission. On the day of admission, he started to experience some abdominal pain in the epigastrium. The patient described it as pressure. It was associated with nausea and vomiting. The patient also stated that he had a poor appetite and could not tolerate food in the morning.

The inpatient hospital stay was not medically necessary for this patient. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care. Overall, he remained in stable clinical condition, his symptoms resolved fast, and he did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. In general, mild alcohol withdrawal symptoms can be managed as an outpatient if the CIWA score is less than 15 and patients do not have a fever, disorientation, drenching sweats, severe tachycardia, hypertension, are not pregnant, do not have concurrent substance use issues that could lead to withdrawal symptoms, and if patients do not have markedly abnormal laboratory values. The review of the medical records demonstrated that the patient did not have these alarming features.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Genetic testing

Diagnosis: rule out cancer
Treatment: Genetic testing
The insurer denied genetic testing. The health plan's determination is overturned. 

The patient is a female who had genetic testing for hereditary breast and ovarian cancer (BRCA). She has three maternal aunts and a maternal grandmother with breast cancer. She has had genetic counseling. There is a question of the medical necessity of the genetic testing.

The requested genetic testing is medically necessary.
Women without a personal history cancer and any of the following should be considered for testing:

1)	Women with 3 or more close blood relatives on the same side of the family with breast cancer
2)	Women with 1 or more close blood relatives on the same side of the family with breast cancer and 1 or more close blood relatives on the same side of the family with ovarian cancer
3)	Women with 2 or more close blood relatives on the same side of the family with ovarian cancer
4)	Women with 1 or more male close blood relatives with breast cancer
5)	Women with 2 or more close blood relatives on the same side of the family with breast cancer, 1 of whom was diagnosed at age 50 years and younger
6)	Women with 1 or more 1st-degree relatives with breast cancer diagnosed at age 45 years and younger
7)	Women with 1 or more 1st-degree relatives with bilateral breast cancer
8)	Women with 1 or more 1st-degree relatives with ovarian cancer
9)	Women with 1 or more close blood relatives with both breast and ovarian cancer
10)	Women of Ashkenazi Jewish descent with 1 or more 1st-degree relatives with breast cancer or two or more 2nd-degree relatives on the same side of the family with breast or ovarian cancer
11)	Women with 1 or more 1st-, 2nd-, or 3rd-degree blood relatives with a known BRCA1 or BRCA2 mutation.

In this case, this patient has 4-2nd degree relatives on her maternal side with breast cancer and therefore is at higher risk for breast cancer and a BRCA mutation. It would be standard of care to perform genetic testing in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus, Pneumonia.
Treatment: Inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is overturned. 
This is a female patient with a history of eczema and persistent asthma with multiple previous hospital admissions for status asthmaticus; one of her previous admission was to the Pediatric Intensive Care Unit (PICU). The patient has had three Emergency Room (ER) visits in the past year for asthma. The patient was sick and coughing for several days and had been receiving albuterol at home with no improvement; she presented to the emergency room for further treatment. In the ER, the patient had mild respiratory distress with associated wheezing and coughing. The patient's chest x-ray was consistent with bilateral perihilar pneumonia. The patient with admitted to the hospital with status asthmaticus. She was treated with intravenous antibiotics, Decadron, Duoneb and then two subsequent treatments with albuterol. The patient was medically stabilized and discharged. 

Based on the review of the medical record and literature, the patient was treated appropriately in the Emergency Room (ER) for persistent coughing and wheezing. When there were ongoing symptoms of persistent wheezing, it was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 3 hours. The patient had failed outpatient management of her asthma and had a history of frequent previous admissions and ER visits for asthma. The patient was a high risk for respiratory failure and was not stable enough to be sent home. Thus, inpatient admission was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be overturned. The medical necessity is substantiated.