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

This patient presented with persistent vomiting and diarrhea. She had several days of nonbloody, nonbilious vomiting. She presented to the emergency room (ER) 2 days prior where lab results revealed carbon dioxide (CO2) 19 but respiratory syncytial virus (RSV), Flu, urinalysis (UA), comprehensive metabolic panel (CMP), chest x-ray (CXR), and abdominal x-ray were all normal. She received a fluid bolus and a glycerin suppository and was sent home. She returned with reports of continued vomiting and worsening by mouth (PO) intake. The patient exclusively breastfeeds and her mother tried to give her Pedialyte but she did not take it. She also developed diarrhea in the interim. Upon return, her CO2 dropped to 16, white blood cell count (WBC) was 17.71. The ER exam documented that the patient appeared dry and crying without any tears. She had dry mucus membranes. The ER doctor documented the inability to tolerate PO intake, decreasing PO intake and more acidosis accompanied by ongoing diarrhea. She was admitted for intravenous fluids (IVF) in the setting of likely viral gastroenteritis. She was started on IVF and Zofran as needed (PRN). She was to have a trial of PO clears with a plan to advance to a bland diet as tolerated. On arrival to the floor, the patient was tired but well appearing. She was started on IVF at 1.5 maintenance. She was noted to be norovirus positive. Fluids were weaned as her PO intake improved on hospital day #2. Throughout admission, she remained hemodynamically stable and afebrile. She was taking good PO with good urinary output (UOP) prior to discharge. The health plan's determination is overturned.
This patient presented with physical findings and laboratory evidence of significant dehydration associated with low decreasing CO2 levels. Apart from this, she had poor PO intake with frequent episodes of diarrheal stools. She had just been discharged from the ER 2 days prior to presentation and returned with persistent symptoms. This patient required IV hydration to compensate for her gastrointestinal (GI) losses that she was unable to match orally. Based on these findings, this patient would meet criteria for inpatient admission for close monitoring of her intake and output (Is and Os) and IVF resuscitation.
She was a candidate for admission due to her inability to maintain oral hydration (eg, needs IV fluid support) that persisted after ER management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Preseptal cellulitis of the right eye

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a female who presented to the emergency department with a past medical history of hypertension, diabetes mellitus, and migraine headaches.  The patient had subjective complaints of nausea, vomiting, right eye swelling, pain x3 days, and chest pain that started the morning of her presentation to the emergency department.  The chief complaint was chest pain, dizziness/fainting, and eye complaints including swelling and pain.  The patient's blood pressure was 172/120.  The patient's temperature was 98.3 F.  The patient's heart rate was 73 bpm and her respiratory rate was 18 breaths/min.  The pain was rated 7/10.  The physical examination revealed the conjunctiva was erythematous bilaterally.  The patient had positive right upper eyelid swelling that was soft.  The patient had pain with movement.  The assessment was likely blepharitis versus conjunctivitis rule out periorbital cellulitis. The patient was hypertensive and there was a low suspicion of acute angle-closure glaucoma. The patient underwent a maxillofacial CT showing soft tissue swelling and inflammatory changes on the right, without abscess.  The patient underwent a consultation with ophthalmology and was diagnosed with preseptal cellulitis of the right eye. The patient was continued with intravenous antibiotics.  The repeat CT scan showed decreased soft tissue swelling and no abscess.  The patient was stabilized, and her symptoms improved. The patient was discharged and was to use oral antibiotics.  

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient. The limitation in ocular motility suggests that there was orbital involvement of the infection.  Orbital involvement would suggest the need for IV antibiotic therapy and hospital admission.  The hospital admission was medically necessary, as orbital cellulitis can progress to involve the cavernous sinus and intracranial structures and if it does progress, it can lead to death or visual loss. 

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Ataxia/Inability to coordinate voluntary muscular movements
Inpatient Hospital

This is a female with history of hypertension and recent bariatric surgery who presented to the emergency department (ED) with complaints of dizziness described as a room spinning with nausea for 1 day. The patient also reported having low blood pressure at home with readings of 70/40 and 45/60. Initial vitals in ED were temp 36.3 C, pulse 77, resp 16, O2 sat 96% on room air, and blood pressure (BP) 96/58. Physical examination was unremarkable except for an abdominal surgical wound. Abnormal laboratory values included potassium 3.3, blood urea nitrogen (BUN) 23, creatinine 1.86, and white blood cell (WBC) 12.82. Brain computed tomography (CT) and renal ultrasound were unremarkable. The patient was admitted for acute kidney injury and vertigo. She was treated with intravenous hydration. BUN was 17, creatinine was 0.99, and WBC 9.12. Blood pressure medication was held with improvement in pressure. The patient was deemed stable for discharge home. In question is the medical necessity of the acute inpatient admission.

The health plan's determination is upheld. The acute inpatient admission was not medically necessary for this patient. The patient's signs and symptoms were thought to be due to dehydration. After appropriate treatment with intravenous fluids in the emergency department, the patient's clinical signs and laboratory abnormalities quickly resolved. The patient was hemodynamically stable. There were no clinical needs, testing or procedures being planned that required inpatient care. There was no evidence of worsening of her condition.
Appeal type: Medical necessity
Decision: Overturned

Obesity
Inpatient Hospital

This patient is a female who sought treatment for the condition of medically complicated, morbid obesity. She completed a multidisciplinary bariatric evaluation. She consulted with a dietitian and received dietary counseling and education. She had a body mass index of 37 kilograms per square meter (kg/m2), comorbidities of diabetes, gastroesophageal reflux disease (GERD), high cholesterol. A mental health evaluation was completed, and she was granted psychological clearance for the proposed bariatric operation. Following completion of her presurgical evaluation, the patient was deemed a suitable candidate for laparoscopic roux en Y gastric bypass (LRYGB).
The subject under review is the medical necessity for the associated inpatient stay which was denied by the health plan.

The health plan's determination is overturned.

Inpatient admission following LRYGB is medically necessary for this patient. Inpatient care is in accordance with generally accepted standards. LRYGB involves general anesthesia and laparoscopic access to the abdomen. There are two intestinal anastomoses and the patient is initially nothing by mouth (NPO) status following surgery. These patients require provision of antiemetic and analgesic medications. The intensity of service for the post-LRYGB patient warrants an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

This patient with a starting program weight of 220 pounds giving a body mass index (BMI) of 37.8 kg/m2. The patient had no weight related co-morbid conditions. An esophagogastroduodenoscopy (EGD) was normal. Sleep study did not confirm sleep apnea. Under review is the medical necessity of a Sleeve gastrectomy and inpatient stay.The health plan's determination is upheld. 
The patient does not have documented morbid obesity at this time. The patient does not have documentation of a BMI that is at least 40 kg/m2 or at least 35 kg/m2 with significant obesity co-morbid conditions such as diabetes, sleep apnea or hypertension at this time. In addition, as noted above, the patient's EGD was normal and a sleep study did not show sleep apnea. Therefore, the sleeve gastrectomy and inpatient stay is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out acute coronary syndrome (ACS)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a male with a history of diabetes, hypertension, current tobacco use, chronic kidney disease, and a positive purified protein derivative (PPD). His home medications included the following; amlodipine, losartan, Lantus, isoniazid, vitamin B6, and vitamin D. The ED triage nurse note lists; Bactrim DS and Percocet, but provider notes do not include these medications.  He presented to the ED with a two to three day history of chest pain, increasing the previous night and awakening him from sleep in the morning. The chest pain was described as severe, mid sternal, radiating to his back and left arm and accompanied by dyspnea, dizziness and nausea.  

The initial vital signs included: blood pressure 147/83, heart rate 70, respiratory rate 18 and oxygen saturation on room air 100%.  The EKG at 12:39 revealed normal sinus rhythm and flat T waves in II, aVL and V6, with no significant change on EKG done.  The laboratory test results included white blood cell (WBC) count 10.2, hemoglobin 13.5, BUN 36, creatinine 2.18, potassium 5.6, sodium 132, high sensitivity Troponin T was 16ng/L, and pro-Brain Natriuretic Peptide (BNP)  14.1. The TroponinT level on the day he presented was also 16ng/L (indeterminate level range is 15-51).  The lack of change is inconsistent with acute ischemia. He was treated with intravenous saline, with blood urea nitrogen (BUN) 37, potassium 4.3 and creatinine 1.97. The chest x-ray was normal. The test results included normal echocardiography and pharmacological stress test, and ultrasound of the kidneys and bladder revealed only bilateral renal cysts. The medication Losartan was discontinued and he was discharged to home for outpatient follow-up, including his other home medications.

There is no evidence of medical necessity for an inpatient hospital level of care to evaluate or treat this patient's chest discomfort. The evaluation to rule out acute coronary syndrome (ACS) could have been completed in the Emergency Department or at an Observation level of care, followed by outpatient testing. The health plan did act reasonably and 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: High Cholesterol levels
Treatment: Repatha
The treatment with Repatha is not medically necessary.

The patient is a male with a history of premature multivessel coronary artery disease and familial hypercholesterolemia. The patient was prescribed evolocumab (Repatha) after LDL (low density lipoprotein) cholesterol remained elevated above goal despite maximally tolerated statin medications.  Cardiac catheterization (2017) revealed 30 % proximal LAD (left anterior descending) disease, 80% mid LAD disease and 70% diagonal disease. The left circumflex artery was diffusely diseased with a 90% lesion of the obtuse marginal artery that was treated with a stent. The right coronary artery was dominant and a 95% lesion of the posterior descending artery was treated with a stent. 

At recent follow up, the patient noted recurrent chest pain and required additional testing. Current medical regimen includes dual antiplatelet therapy and rosuvastatin 40mg daily. Ezetimibe10mg daily was initiated at an at the beginning of the this month visit.  Cholesterol panel demonstrated total cholesterol 151, HDL (high density lipoprotein) 53 and LDL 76.

This patient is a male with severe premature atherosclerotic coronary artery disease, on maximally tolerated high intensity statin treatment (rosuvastatin 40mg daily) LDL cholesterol 76mg/dl (Above the goal of less than 70mg/dl). Addition of a non-statin agent such as Ezetimibe is indicated and may allow for significant reduction in LDL cholesterol.  Current American Heart Association and American College of Cardiology guidelines recommend addition of Ezetimibe therapy to maximally tolerated statin therapy in such patients (Reference 1).  Medical records indicate that Ezetimibe was initiated at the at the beginning of the month visit.  Should the combination of Ezetimibe plus statin therapy fail to significantly reduce LDL cholesterol, then addition of Evolocumab would be indicated (Reference 1,2).  

In conclusion, the proposed treatment with Repatha is not medically necessary.  Treatment with Ezetimibe followed by repeat cholesterol panel is indicated prior to initiating additional therapy.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient  who presented to the emergency department (ED) with shortness of breath, sweating, palpitations and left sided chest pain radiating to the left arm and around the left upper back. The pain started the night before at 11 pm. The pain in the back was sharp, and worse with deep inspiration. The patient took Percocet and nitroglycerin at 1 am and it helped. The patient went to sleep and woke up at 6 am with the same pain. He also had shortness of breath, sweats and palpitations.
The patient's Troponin was normal. His laboratory studies were unremarkable. His chest x-ray (CXR) revealed lingular opacities relatively unchanged in comparison to the prior examination of the chest. Superimposed patchy left basilar infiltrate cannot be excluded.The health plan determination is upheld in whole .
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient has severe cardiac disease. The patient  has an ischemic cardiomyopathy with a low ejection fraction (EF). The patient  had an old myocardial infarction (MI), and an apical thrombus. the  serial cardiac enzymes were normal. The patient's echocardiogram was unchanged from the previous study. The  laboratory studies were unremarkable. The  CXR revealed lingular opacities relatively unchanged in comparison to the prior examination.
During this admission, there was no evidence of new cardiac events. The patient's  chest pain most likely was not ischemic. The patient's  heart failure exacerbation was mild. The management of this patient did not change during this admission.The level of care provided for this patient did not meet inpatient criteria. A lower level of care was more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Growth Hormone Deficiency
Treatment:  Growth Hormone

The patient is male who is seeking growth hormone (GH) treatment.  By history, he has been growing between 10-20th percentile for height.  His mother's height is 64.5 inches, and father's height is 73.5 inches.  His mother had reached menarche at age 14 years, and father was late in his puberty.  He has been diagnosed with celiac disease by his primary care provider, and he is on gluten free diet.  His evaluation for short stature on was unremarkable including complete blood count (CBC), thyroid function test, celiac screen and chemistry profile.  His IGF-1 (insulin like growth factor 1) was 211 ng/ml (112-454) and IGFBP-3 (Insulin-like growth factor-binding protein 3) was 3.799 mg/L (2.385-5.956).  His bone age was read as 2 years delayed.

The health plan's determination is upheld.  Nutropin is not medically necessary for this patient.  This patient is relatively short for his genetic potential (mid parental height 71.5+/-2''), but by history he has been growing between 10-20th percentile for height and has family history of late puberty, suggesting the possibility of constitutional delay in growth and pubertal development.  Children with constitutional delay constitute one of the commonest clinical problems encountered in pediatric endocrine clinics.  It is defined by Prader as: "constitutional delay of growth occurring in otherwise healthy adolescents with stature reduced for chronological age but generally appropriate for bone age and stage of pubertal development, both of which are usually delayed."
This patient's bone age was delayed, which is consistent with constitutional delay, and his evaluation was unremarkable including normal IGF-1 and IGFBP-3 making GHD unlikely.  Nonetheless, he underwent GH stimulation testing, and his peak GH response was 10 ng/ml (not less than 10) arguing against GHD.  His response was normal despite the fact that GH stimulation testing was done in a suboptimal condition, which can falsely lower GH peak.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell crisis; streptococcal pharyngitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a female with sickle cell disease brought to the Emergency Department for respiratory distress, cough, congestion and throat pain have been reviewed.  Of note, the patient had markedly elevated white blood cell (WBC) count. CT scan Impression: 1) Mild to moderate chronic sinus disease involving the ethmoid air cells, sphenoid sinus and maxillary sinuses. 2) Large soft tissue mass like density is incompletely visualized in the nasopharyngeal region measuring approximate 4.5 x 2.9 x 3.4 cm.  This also extends inferiorly and appears to significantly narrow the airway.  Malignancy or abscess should be considered.  Further evaluation with contrast-enhanced CT of the maxillofacial region and neck are recommended.  Individualized dose optimization techniques were used for this CT. The patient was admitted with a diagnosis of sickle cell crisis and concerns of streptococcal pharyngitis.  The patient received supportive care and antibiotics. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is considered medically necessary for this patient.

Patients with sickle cell disease are known to be at risk for overwhelming infection.  Based on nationally accepted guidelines, an elevated WBC >30, in and of itself, could justify hospitalization for intravenous (IV) antibiotics.  In this patient with shortness of breath, a CT concerning for an abscess vs mass, it was clearly within standard of care to provide antibiotics and close monitoring within an inpatient setting.  The complexity of this presentation, especially with that degree of WBC elevation required inpatient care to mitigate the risk of poor outcome from potential overwhelming infection.  Admission was within standard of care.

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital

The patient is an infant born who presented to the emergency department (ED) for evaluation after a fall. He had fallen approximately 2.5 feet from the bed, unwitnessed, striking the parquet floor. There was no loss of consciousness, but he developed right parietal swelling. He cried immediately for a couple minutes, and then fell asleep. He had no vomiting and was able to feed en route to the ED. He was initially seen by the pediatrician, then subsequently referred to the ED for further evaluation. Vital signs included temperature 36.8, heart rate 164, respiratory rate 36, blood pressure 88/54, and 100% saturation in room air. Physical examination was significant for moist mucosa, right parietal hematoma with no step-off, clear lungs, normal perfusion, benign abdomen, and non-focal neurologic exam. Head computed tomography (CT) was obtained, revealing an acute non-displaced, non-depressed high right parietal skull fracture with overlying extracranial subgaleal hematoma, as well as a questionable sub-centimeter hyperdensity in the left inferior parietal cortex possibly representing a very small contrecoup hemorrhagic contusion. Neurosurgery was consulted, with recommendations to admit to the Pediatric Intensive Care Unit (PICU) for observation. 

The health plan's determination is upheld. This young infant fell from the bed onto a wooden floor, resulting in closed head injury with right parietal non-displaced skull fracture, subgaleal hematoma, and small contrecoup intraparenchymal hemorrhagic contusion. This was a non-operable injury, but because of his age and the extent of the injury, overnight observation was medically necessary and appropriate, consistent with current recommendations. However, because he was overall stable, with no cardiorespiratory issues, able to feed normally, with normal age-appropriate behavior and no neurological abnormalities, he did not require acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Prostate Cancer 
Cancer Screening 

The patient underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed a Gleason 6 adenocarcinoma in 2 out of the 12 cores. The clinical stage was T1c. An OncotypeDx test was ordered on the biopsy specimens. The health plan's determination is upheld in whole.
The Oncotype Dx testing is not medically necessary.
The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer.
While Oncotype dx may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain 
Treatment: Inpatient admission 

Summary:
The patient is a male. He presented to the ED with diffuse abdominal pain, 7-8/10 in severity, tenesmus and occasional blood in the stools. He endorsed c/o (complaints of) chronic abdominal pain for the prior five to six months. He also complained of two to three bowel movements per day for prior two to three months. His past medical history is remarkable for exploratory laparotomy and resection of the small bowel for GI (gastrointestinal) bleed from arteriovenous (AVM) malformation in 2012.

The Inpatient admission was not medically necessary for the management of this patient's condition. 

The patient was admitted with abdominal pain and diarrhea, tenesmus and occasional blood in the stools. In the ED, he was hemodynamically stable and afebrile. The labs, including CBC and CMP (comprehensive metabolic panel) were normal. CT scan of the abdomen revealed mild sigmoid diverticulitis with no evidence of abscess requiring drainage, or any bowel obstruction of perforation requiring any surgical intervention. He was treated with two days of IV antibiotics. During his hospitalization, he remained hemodynamically stable and tolerated liquid diet well without any nausea and vomiting. He was discharged home on oral antibiotics for the treatment of diverticulitis. Given this clinical scenario, the acute level inpatient care was not medically necessary, and the patient could have been safely managed under the lower level of care.