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

Diagnosis: Skin Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female with a history of diabetes and depression. She presented to the emergency room with a two-week history of an "abscess" draining from her buttock. Her vital signs were normal, she was in no acute distress, and did not appear toxic. Physical exam was notable for a 12 centimeter (cm) circular area of erythema surrounding a 4 cm area of fluctuance in her right buttock. Labs were notable for a white blood cell (WBC) count of 14,900 and a glucose of 385 milligrams per deciliter (mg/dl). The abscess was incised and drained in the emergency room and the wound was packed. Intravenous antibiotics were initiated. The pelvic computed tomography (CT) scan completed after the incision and drainage revealed a 5 cm focal infiltration within the subcutaneous tissue, with soft tissue gas; the gas did not extend into the musculature. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous antibiotics and long-acting insulin. The following day, she was afebrile and in no pain. The WBC count was down to 11,000 and the glucose was down to 306 milligrams per deciliter (mg/dl). The remainder of the stay was clinically uneventful, and she 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, or imaging of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no pain. She was afebrile, hemodynamically stable, with a normal mental status. Her glucose was moderately elevated but there was no evidence of severe metabolic disarray. The CT scan showed no evidence of deep tissue involvement. The services provided - incision and drainage, intravenous antibiotics - did not require acute inpatient care. Therefore, based on the standard of care, and the peer reviewed literature cited below, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical chest pain
Treatment: Inpatient admission 

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

The patient is morbidly obese and presented to the hospital complaining of chest pain, left sided jaw pain and left arm numbness for two days. Symptoms were associated with chest movement. She was evaluated two weeks earlier at the hospital for similar complaints.  Past medical history was significant for gastroesophageal reflux disease, hypertension, and atrial fibrillation. Upon arrival to the hospital, vital signs were stable; blood pressure of 155/82, pulse of 104 beats per minute. Physical examination was within normal limits.  A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm without ST (interval on ECG) or T (interval on ECG)  wave (interval on ECG) abnormalities.  Serum blood testing revealed no elevation in serum troponin and no elevation in B type natriuretic peptide of D-dimer levels.  The patient was admitted to the hospital for observation and treatment. Echocardiogram revealed a left ventricular ejection fraction of 50-55 percent without wall motion abnormalities. The patient was ultimately discharged home with cardiology follow up. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical chest pain and a past medical history of hypertension, atrial fibrillation, and gastroesophageal reflux disease. Her pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (history, ECG anomalies, patient age, risk factors, and Troponin) score she was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction, need for percutaneous coronary intervention, need for coronary artery bypass grafting, or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, myocardial infarction, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary; this patient could have been treated at a lower level of care.

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 admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia due to symptomatic fibroids
Treatment: Inpatient hospital admission 

The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient has a history of anemia due to symptomatic fibroids. She underwent a robotic-assisted laparoscopic hysterectomy and bilateral salpingo-oophorectomy (BSO) without complications. Blood loss was 10 cubic centimeters (cc). The surgery was without complication. Postoperatively, the patient was doing well with no complaints. She was noted to have an elevated white blood cell count (WBC). As per progress note, there were no signs of infection. Intravenous (IV) medications and IV antibiotics were given. The next day, the patient's bloodwork and vitals were stable. She was discharged home with follow up with the surgeon's clinic.

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 Milliman Care Guidelines, Inpatient and Surgical Care 24th Edition, Laparoscopic Hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. An inpatient stay may be needed for: surgical complications (bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, complex surgery (staging of endometrial cancer), wound complications and/or comorbidities. This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. While her WBCs were elevated, that is expected after surgery and as per provider, the patient was doing well with no sign of infection.

According to the scientific literature, routine measurement of WBC after robotic hysterectomy is not useful. In about 25 percent of cases there will be a slight leukocytosis, and rarely (about 4 percent) will the WBC exceed 15,000/microliter. In no case was measurement of postoperative WBC clinically relevant.

Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

Based on the above, the inpatient admission was not medically necessary.

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 the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a nonbinary adult who initially presented to the emergency department with concerns for lip peeling and bilateral foot pain for several day duration. Pertinent history included prior hospitalization where a dermatologist cleared the patient from Stevens-Johnson syndrome due to no cutaneous involvement and prescribed Keflex. Additional history included attention deficit hyperactivity disorder, bipolar disorder, depression, mood disorder, and neurofibromatosis syndrome.

Active treatment included oral azithromycin and topical supportive care. There were no new issues. Chest radiograph was unremarkable. Ophthalmology consultation was obtained who did not document ocular involvement and recommended artificial tears. Treatment plan was continued. There was continued clinical improvement. There was no change in the treatment plan. Infectious disease consultation was obtained who recommended oral azithromycin for 5 days and avoidance of lamotrigine. The patient was discharged with outpatient follow-ups.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary based on the clinical documentation provided, evidence-based literature and standards of care.
The patient had a history of a dermatologic reaction following lamotrigine initiation as well as shellfish exposure and was treated at a different hospital prior to presentation. The patient then presented for continued symptoms. An extensive and comprehensive evaluation was performed and unremarkable for any systemic or organ involvement. No eosinophilia was noted, and SJS/TEN was ruled out by a dermatologist at the previous hospitalization and by the dermatologist during this hospitalization. The active treatment plan consisted of oral azithromycin and supportive topical medications. Multiple consultations were obtained and agreed with the treatment plan followed by recommendations for outpatient follow-up. Following observation care, clinical improvement was noted and no further issues or complications requiring an inpatient level of care were documented.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with a past medical history remarkable for diabetes, hypertension, and anxiety, who was admitted for elevated blood pressure, dizziness, nausea, and abdominal pain. Review of system was negative for additional symptoms.
The patient was afebrile (Temperature of 99.6), described as well appearing and no acute distress. Her blood pressure was 116/72, pulse rate of 82, respiratory rate of 20, and oxygen saturation of 96% on room air. Physical examination was remarkable for epigastric pain.
Laboratory evaluation demonstrated a sodium of 122, potassium 3.6, chloride of 93, carbon dioxide (CO2) of 19, blood urea nitrogen (BUN) of 6.26, creatinine of 0.6, glucose of 138, white blood cell count (WBC) of 7.8, Hgb (hemoglobin) of 12.2, Hematocrit (HCT) of 34.8, and platelet of 251. Chest x-ray revealed small left pleural effusion. A computed tomography (CT) scan of the chest revealed evidence of small pleural effusion. The patient was admitted for hypertensive urgency/emergency.

The inpatient hospital admission was medically necessary.
The patient was admitted for moderate hyponatremia (serum sodium of 122). The documentation supports inpatient level of care for electrolyte stabilization was urgent and medically necessary. At the time of admission, the patient was described with dizziness, nausea which are manifestations of symptomatic hyponatremia and limits oral intake. As such, careful and gradual sodium correction was necessary at the inpatient level.
Symptomatic hyponatremia is associated with grave consequences including cerebral edema, brain herniation, seizures, obtundation, coma, and respiratory arrest. Furthermore, rapid correction of chronic severe hyponatremia may lead to osmotic demyelination syndrome and even death. Given the serious consequences of severe hyponatremia or its inadvertent over-correction, it is of paramount importance for the clinician to conduct ongoing treatment and monitoring to assess for improvement.
From a hypertensive urgency standpoint, the patient's blood pressure stabilized and clinically improved. The indication for admission was electrolyte imbalance that required inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Vein Thrombosis

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission

The denial is upheld.

This patient presented to the emergency department (ED) with lower extremity pain. He indicated he had a right leg deep vein thrombosis (DVT). He was taking Eliquis however, he was not tolerating medication. He was sent to the hospital for a possible heparin drip. Documentation indicated that the right lower extremity appeared swollen and reddened from the knee down. The patient reported pain and stiffness to the area. The patient was admitted for further management of the DVT in addition to a pulmonary embolism (PE). Throughout his stay there were no documented deficits that worsened. He continued to improve and was discharged with instructions for outpatient follow-up.

This patient with right leg pain that the week prior to admission was diagnosed with a right calf DVT and was placed on Eliquis. He presented to the ED on the recommendation of his physician as he was "not tolerating" the Eliquis. Upon arrival into the ED, he had no shortness of breath, dyspnea, or chest pain. There was some edema to the right leg. There was no evidence of any auto-immune reaction. His vital signs were stable and there was no evidence of hypoxia or pulmonary issues. In multiple areas of the chart, there was documentation of no shortness of breath or chest pain.

For reasons that are unclear, the patient was converted to a heparin drip, and for other reasons unknown, in spite of there being no clinical findings or echocardiogram (ECHO) findings, a computed tomography (CT) with pulmonary embolism (PE) protocol was ordered. It did show right sided subsegmental PE but no major PE to the main trunks. Over the next two days the patient was converted back from the heparin drip to Xarelto. His course was uncomplicated.

The prescription for Eliquis could have been changed in the ED itself to Xarelto, and/or low molecular weight heparin, and the patient sent home.

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 hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism (PE)
Treatment: Hospital Admission

The insurer denied coverage for Hospital Admission.
The denial is upheld.

The patient has a history of pulmonary embolism (PE), not on anticoagulation at the time. He presented to the emergency department with complaints of shortness of breath on exertion for the prior weeks. The patient had been seen at another facility the previous week when an echocardiogram was done which was normal and bilateral lower extremity dopplers were done which were negative for deep vein thrombosis.  Vital signs on presentation were temperature 98.4, heart rate 111, respiratory rate 24, blood pressure 144/95. Oxygen saturation was 95% (percent) on room air. The patient was in no acute distress, was speaking in full sentences and was alert and oriented to person, place, and time. Lung sounds were clear and cardiovascular system exam revealed tachycardia. Neurological exam was normal.  Lab work revealed normal electrolytes with elevated D-Dimer at 6.33 and mild elevation of Troponin to 0.035. The patient had a computed tomography angiography (CTA) done which revealed bilateral PE with evidence of right heart strain.  

The patient was admitted to the hospital for PE and started on Lovenox. The patient remained stable after admission. An echocardiogram (ECHO) was done which revealed a normal ejection fraction (EF). The patient was in no acute distress (NAD) and remained afebrile and hemodynamically stable without hypoxia.  The patient was seen by Cardiology. There was no active intervention recommended. They felt his mild elevation in Troponin was from PE and not acute coronary syndrome (ACS).  The patient was ambulatory, tolerating oral intake (PO), was in NAD, saturating 95-98% on room air (RA). He was switched to oral Xarelto and discharged home the next day.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated.
The patient remained stable after admission, was afebrile, hemodynamically stable. Myocardial infarction was ruled out. He could have been discharged home on oral anticoagulants after a period under observation with close follow up in the outpatient setting.

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

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

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient hospital. 

The insurer denied inpatient hospital stay. 
The health plan's determination is upheld. 

This is a female who presented to the emergency room (ER) with a three-week history of diarrhea about six times (6x)/day. The patient's mother reported stool was initially green then one week prior it turned orange/brown. She saw her primary medical doctor (PMD) the week prior regarding this two times and both times PMD requested stool studies. The first time the results were unremarkable and the second one was recently with no results available. The patient's mother states that the child lost her appetite on the morning of presentation, and she vomited clear secretions once in ER. She normally eats 3-4 meals a day. The patient's mother reported the patient had a weight loss with weight of 27.2 the day before and 26.5 on day of presentation. The patient had a mild rash in genital region which started three weeks prior. PMD prescribed antifungal that did not work, then Aquaphor which worked and relieved the rash. The patient's mother denies jaundice, couch, runny nose, wheezing, urine discoloration, loss of consciousness (LOC) or seizure. The subject under review is the medical necessity for the inpatient hospital stay. 

The health plan's determination is upheld. 

The requested inpatient hospital stay was not medically necessary for this patient. This patient presented with three-week history of diarrhea with one day history of decreased by mouth PO intake and one episode of emesis. There were no physical findings to support a diagnosis of dehydration. Per the gastroenterologist, the patient's diarrhea actually started to improve and decrease in frequency during the week prior to admission to the hospital. She did not have any markedly abnormal laboratory values apart from a low glucose which was addressed in the ER. She did not have documented PO intolerance, unstable vital signs, decreased urine output, PO refusal or any finding concerning enough to warrant inpatient level of care. The patient could have been treated at a lower level of care status.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Heartburn, epigastric pain and bloating
Treatment: Upper GI endoscopy- esophagogastroduodenoscopy with radiofrequency ablation (RFA)
The insurer denied Upper GI endoscopy- esophagogastroduodenoscopy with radiofrequency ablation (RFA).
The determination is upheld.

The patient has a history of morbid obesity status/post (s/p) Roux-en-Y gastric bypass (RYGB), hiatal hernia status/post (s/p) repair with complaints of ongoing gastroesophageal reflux disease (GERD), epigastric pain and bloating. An upper gastrointestinal (UGI) study showed normal anatomy. Esophageal manometry showed some ineffective motility with low resting lower esophageal sphincter (LES) pressure. A 24 hour potential hydrogen (pH) study did not reveal an elevated DeMeester score.
At issue is whether the Upper GI endoscopy- esophagogastroduodenoscopy with radiofrequency ablation (RFA) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

There is limited data to support the use of Stretta or radiofrequency ablation (RFA) for the treatment of post bariatric GERD, particularly, non acid GERD. There is only one trial of the use of RFA in post gastric bypass patients which all were found preoperatively to have acid exposure with an elevated DeMeester score. Although clinical options for this patient are limited, given her history of gastric bypass (eliminating the ability to perform surgical anti-reflux procedures such as Nissen fundoplication, transoral incisionless fundoplication (TIF) or LINX), there is limited data to support that RFA is likely to be more beneficial than standard treatment for this patient's non acid GERD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Failure to Thrive

Treatment: Acute inpatient stay

The insurer denied coverage for acute inpatient stay.

The denial is upheld.

The patient was homeless and had a history of diabetes, hypertension, cardiac disease, and chronic alcohol use. He was transferred to the hospital for failure to thrive and weakness. He was hemodynamically stable. The chest exam was clear and the abdomen was benign. There was no chest infiltrate. There was no leukocytosis. A computed axial tomography (CAT) scan was read as a possible gastroenteritis. An extensive workup was done to look for a malignancy. Hepatitis serology was ordered. PPI (proton pump inhibitor) therapy was given for gastritis. Adjustments were made to his diabetes regimen. An endoscopy revealed esophageal candidiasis and Fluconazole was given. Lower extremity weakness was attributed to lumbar radiculopathy. The social worker attempted to arrange for placement in a rehab facility.

This patient was non-compliant with his medical care and required a workup for weight loss and weakness. There was a concern that he could have an occult malignancy or a serious systemic condition. Milliman Care Guidelines (MCG) list clinical indications for admission for Systemic or Infectious Conditions. These include hemodynamic instability, severe electrolyte abnormalities, unexplained hypoxemia, a suspected severe infection, and a body mass index (BMI) less than 18.5. In this case, the chart does not document a BMI consistent with severe malnutrition. The patient did not meet these criteria.

The patient did require an urgent evaluation for failure to thrive and weakness. However, he was stable to have had this workup done on an ambulatory basis. He did not meet MCG criteria for Systemic or Infectious Conditions. The health care plan acted reasonably and with sound medical judgement. An inpatient hospitalization was not medically necessary.

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 acute inpatient stay is upheld. Medical necessity is not substantiated.