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

This is a patient who was admitted for shortness of breath, a cough and wheezing. On initial evaluation, she was afebrile, hemodynamically stable but noted to have respiratory distress briefly with bilateral wheezing and decreased air entry. After 24-hours of treatment with intravenous methylprednisone, albuterol nebulizers, magnesium and briefly requiring supplemental oxygen and bi-level positive airway pressure (BiPAP), she was noted to have an improvement in her respiratory status with resolution of her wheezing and respiratory distress. The health plan's determination of medical necessity is upheld in whole. On evaluation by the critical care physician, the patient was noted to be hemodynamically stable, was not in respiratory distress, was breathing comfortably, her wheezing resolved and her lungs were clear bilaterally, she no longer required BiPAP ventilation and was eating. In addition, she did not have any dysrhythmias, her chest x-ray did not show any pneumonia, she never had an altered mental state and although she briefly required BiPAP and supplemental oxygen her clinical condition improved within 24-hours. The patient did not have the clinical risk factors indicated for an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

This patient had a history of an appendectomy.  A colonoscopy revealed a deformity of the appendiceal orifice.  No biopsy was obtained of this area.  An endoscopy revealed Helicobacter Pylori associated gastritis.  The physician has requested a magnetic resonance imaging scan to evaluate the appendiceal abnormality.  The insurer has advised that a computerized axial tomography scan is the preferred imaging study.

The insurer denied coverage for the magnetic resonance imaging scan.  The denial was upheld.
  
Milliman Care Guideline A-0044 discusses magnetic resonance imaging testing. An abdominal magnetic resonance imaging scan may be indicated for an intra-abdominal mass.  However, it is only indicated after an abnormal ultrasound or if a computerized axial tomography scan is contraindicated, not available, or the results are indeterminate. In this case a computerized axial tomography scan has not been done to visualize this area.  Therefore, the patient did not meet criteria for obtaining a magnetic resonance imaging scan.  The patient could have the preferred imaging study with a computerized axial tomography scan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colon Cancer
Treatment: Advanced Imaging (CT scan)

Summary: This patient with a history of stage 1 colon cancer underwent a robotic assisted right hemicolectomy for malignant neoplasm of the ascending colon (T1N0M0) adenocarcinoma in 2018. A progress note from 2017 indicated that the patient presented to the office of his Colorectal Surgeon for evaluation of colon cancer involving the ascending colon. The tumor was identified by colonoscopy and evaluation was prompted by family history for colon cancer. The tumor was biopsied and histology showed a moderately differentiated tumor. A Computed Tomography (CT) scan of the abdomen and pelvis revealed that metastatic disease was absent. The patient underwent a robotically assisted laparoscopic right hemicolectomy in 2018 with pathology revealing an invasive adenocarcinoma well differentiated arising in a tubulovillous adenoma with high grade dysplasia of the ascending colon. It invaded the superficial mucosa, and there was no lymphovascular or perineural invasion identified. The proximal, distal and radial margins of resection were negative for adenoma or carcinoma. Thirty six benign reactive lymph nodes were seen, none with metastatic carcinoma. A follow-up visit note indicated that the tumor was a T1N0M0 adenocarcinoma.  As per a progress note, the provider indicated that no further treatment was required other than carcinoembryonic antigen (CEA) levels and CT scans for surveillance.  The plan was for follow-up in one year.  This was a stage 1 colon cancer.

The insurer has denied coverage for CPT code 74177- computed tomography (CT) of the abdomen and pelvis with contrast as not medically necessary. The denial was upheld.

This patient had a well differentiated adenocarcinoma arising in a tubulovillous adenoma. The patient underwent a right hemicolectomy and the tumor was determined to be a stage 1 colon cancer with staging being T1N0M0. Based upon National Comprehensive Cancer Network (NCCN) guidelines, surveillance for stage 1 disease imaging is not recommended and should only be used for symptoms and clinical concern for recurrent/metastatic disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure
Treatment: Inpatient Hospital Services

Summary: This patient's history is significant for polysubstance abuse, self-harm behaviors, anxiety, and depression.  The patient also had a history of three prior seizures, but he was not on medication.  The patient was brought to the Emergency Department (ED) by his sister after she witnessed a seizure with associated vomiting.  There were no acute findings on Computed Tomography (CT).  The treating provider was called to the patient's bedside due to active seizing while in the ED.  Ativan and Keppra were ordered.  The patient was diagnosed with seizure and anxiety and admitted for further evaluation and treatment.  In an appeal, it was detailed that the patient had a history of seizures with his last seizure occurring three years prior.  The patient then had a witnessed grand mal seizure while in the ED. 
 
The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was reversed. 

Inpatient admission for recurrent seizure was in accordance with Milliman Care Guidelines (MCG). According to MCG, inpatient admission is indicated for seizure for patients with hemodynamic instability, status epilepticus, cardiac arrhythmias, severe or persistent altered mental status, new neurological deficits, recurrent seizure (during ED or observation care), and when outpatient anti-seizure regimen cannot be established.  The patient had a witnessed grand mal seizure while in the ED after a witnessed tonic-clonic seizure at home.  As the patient had a recurrent seizure during ED care and an outpatient anti-seizure regimen had not been established, an inpatient level of care was indicated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who sought surgical evaluation for the condition of GERD [heartburn]. He has used prescription antacid medications, but has breakthrough and refractory symptoms.  The treating surgeon has proposed the LINX procedure as treatment of chronic GERD. The health plan's determination of medical necessity is overturned in whole.  This patient has symptoms of GERD and has proven pathologic esophageal acid exposure, preserved esophageal motility and no alternative diagnosis or precaution to an antireflux procedure. Standard of care treatments include ongoing medicinal treatment, laparoscopic Nissen fundoplication, transoral incisionless fundoplication (TIF), and the LINX magnetic sphincter augmentation procedure. LINX offers improved outcomes compared to ongoing medicinal treatment and is on par with the reduction of esophageal acid exposure seen following fundoplication, but with improved ability to belch and vomit compared with fundoplication. This patient has been appropriately evaluated for the condition of GERD.  Patient has completed objective testing with EGD that showed an irregular Z-line with minimal hiatal hernia. pH testing confirmed elevated esophageal acid exposure with a DeMeester score of 59.8 over 24-hours. Esophageal fluoroscopy showed normal peristalsis and esophageal motor function. Esophageal motility also confirmed no motor dysfunction to contraindicate an anti-reflux procedure such as LINX. An antireflux procedure such as LINX is appropriate therapy based on the documentation provided.  This procedure is medically necessary.  LINX has been granted Food and Drug Administration (FDA) approval since 2012.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute kidney injury
Treatment: Inpatient admission
The proposed inpatient admission was not medically necessary.
The patient underwent an uncomplicated ultrasound guided right renal biopsy.  The patient's hematocrit (HCT) was 26.4% at 0850 hours before the procedure and 24.1% at 2010 hours.  There were no red flags to warrant hospital admission.  The patient had no complaints following the procedure, specifically no flank pain or hematuria, to suggest hemorrhage from the renal biopsy.  The drop in hematocrit may have been due to intravenous (IV) hydration.  Biopsy guidelines published by the Society of Interventional Radiology (SIR) do not list any specific time frame for postprocedural care, but other SIR guidelines state that a small percentage of patients will have prolonged symptoms that require a greater level of postprocedural care.  This patient's medical record does not indicate a need for a greater level of postprocedural care; therefore, the acute inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of Type 2 diabetes mellitus on insulin, peripheral neuropathy, amputated toe, coronary artery disease status-post stent, hypertension, and dyslipidemia. The patient presented to the hospital from cardiologist for workup of intermittent atypical chest pain associated with pain with arm movement and shortness of breath on exertion. The insurer has denied coverage for the inpatient hospital services. The denial was upheld. This patient has coronary artery disease and had a percutaneous coronary intervention done in 2017. Recently she presented to her doctor complaining of intermittent atypical chest pain which occurred with arm motion. She had a nuclear stress test done in 2018 but did not present for an elective percutaneous coronary intervention until 2019, which is not consistent with a diagnosis of unstable angina, which was included in the physicians reasoning for hospital admission. During this elective admission for an elective procedure she had no complaints of chest pain, her troponin values were within normal limits and her electrocardiogram showed no changes. The procedure was done in a short period of time with no complications described. Her post procedure course was uneventful with no abnormalities noted in her right wrist which was the access site. As indicated in the research cited, hospital admission for this type patient is no longer the accepted procedure. The inpatient hospital services were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: In patient admission, diagnostic evaluation, medication management

The insurer denied inpatient admission. That denial was upheld.

The patient presented with abdominal pain, vomiting, and diarrhea.  He was afebrile and the vital signs were stable.  There was no abdominal rebound or guarding.  There was no leukocytosis.  The renal function was normal.  A CAT scan was negative, except for trace free fluid in the pelvis.  The patient was diagnosed with acute gastroenteritis.  Intravenous (IV) hydration, Famotidine and anti-emetics were given.  The diet was gradually advanced.

Clinical indications for admission for Gastroenteritis (M-170) include a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, toxic megacolon, and hemodynamic instability.  The patient did not have these conditions.  Severe dehydration is an indication for admission if there is a 3-fold rise in serum creatinine or a sodium over 150.  The patient did not have these conditions.  The patient also did not have severe vomiting as it subsided with anti-emetics.

This patient had gastroenteritis.  He required intravenous hydration and antiemetics.  However, he could have received this with observation status.  By the next day, his symptoms were much improved and the diet was advanced.  He did not meet MCG criteria for admission for gastroenteritis.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder with co-morbid cannabis use disorder and severe opioid use disorder in treatment with a methadone maintenance treatment program (MMTP).

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient in this case presented with a diagnosis of severe alcohol, opioid, and cannabis use disorders. The patient also has severe psychosocial stressors with limited support and functional impairments. The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol and opioid and cannabis use disorders did warrant the admission and continued inpatient level services with medical monitoring. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been provided at a lower level of care in this case scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Issue under review: Inpatient admission
Summary: The inpatient admission was medically necessary.
"The patient does not meet CURB-65 scores that indicate high rates of mortality given by the Infectious Diseases Society of America. However, standard of care would dictate admitting such a patient as this as the ER attending thought the patient was in "serious condition", and they had documented hypoxia, respiratory distress, and accessory muscle use. These are all indications of increased work of breathing that can precede respiratory failure. Her further hospitalization was necessary to evaluate the severe pneumonia, and diagnose and treat potentially exacerbating conditions (anemia and hypothyroidism). Thus, this admission was warranted by standard of care. Failure to admit such as a patient can lead to respiratory failure or death."
Appeal type: Medical necessity
Decision: Upheld

This patient presented to the Emergency Room with a complaint of severe abdominal pain, nausea and vomiting.  He has a past medical history of cirrhosis, alcoholic hepatitis, calculus of gallbladder, hypertension and diabetes mellitus.  Diagnostic imaging showed gallbladder stone.  He was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding.  The liver enzymes were elevated.  The international normalized ratio (INR) was normal.  An abdominal ultrasound revealed cholelithiasis.  There was no evidence of acute cholecystitis or bile duct dilatation.  The patient was felt to possibly have alcoholic hepatitis.  A magnetic resonance cholangiopancreatography scan was planned, but the patient could not complete the exam.  The liver enzymes gradually improved.  No surgical interventions were needed at this time for the cholelithiasis.  A work-up was ordered to evaluate the cause of the rise in the liver enzymes. The patient's pain resolved.

The insurer denied coverage for the inpatient hospital services. The denial was upheld.
 
Per Milliman Care Guidelines, clinical indications for admission for liver disease complications (M-570) include hepatic encephalopathy, hemodynamic instability, peritonitis, or severe liver disease.  This patient does not have severe liver disease.  This is further supported by the fact that the INR was normal at 1.1.  For alcoholic hepatitis, the patient would have a Model End Stage Liver Disease score of 20 or more.  The patient did not meet these criteria.  He also did not have severe pain, severe vomiting, or severe dehydration.  This patient had hepatitis but no evidence of liver failure.  The gallstones did not require any surgical interventions at this time.  The liver enzymes gradually improved and the pain resolved.  The patient was stable to have had the liver enzymes monitored as an outpatient.  He was hemodynamically stable and able to tolerate a diet.  He was stable for outpatient management.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypertension, peripheral artery disease with stents to the distal superficial femoral artery (SFA), mid superficial femoral artery (SFA) and popliteal arteries, obesity, and tobacco dependence, who presented with a chief complaint of chest pressure. She reported that the pressure radiated to her back and both shoulders, was associated with shortness of breath and intermittent dizziness and palpitations.The health plan's determination of medical necessity is upheld in whole.
This patient who had several risk factors for acute coronary syndrome and presented with chest pressure was appropriate for a lower level of care of care and stress testing. In the absence of laboratory or EKG evidence of ischemia or other process such as dissection, pulmonary embolism, malignant arrhythmia, pericardial effusion, or other process requiring inpatient care, admission at the acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is an adult female who presented on 09/21/2018 for inpatient substance use disorder rehabilitation treatment to address alcohol use disorder. The requested substance use disorder rehabilitation services for alcohol use disorder could have been safely and effectively provided at a lower level of care in this case scenario including sober housing and other supportive services in the community, as well as peer support through Alcoholics Anonymous and the obtainment of a sponsor. 

The patient in this case did not experience significant general medical, biomedical (alcohol withdrawal), or psychiatric complications despite a history of trauma and recent losses and deterioration in functioning. The patient was motivated for treatment and there were no emotional issues that required residential level structure or monitoring in this case. Additionally, the patient had sober supports from family and a stable living situation that could support her treatment of the alcohol use disorder.

The requested health service/treatment of inpatient substance use rehabilitation treatment 09/21/2018 through 10/05/2018 is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Perianal abscess
 
Treatment:  Inpatient admission, medication, monitoring

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

This patient presented to the Emergency Room with hemorrhoidal pain.  The patient had been using suppositories but had no relief.  The patient denied bleeding.  The pain was rated 7/10.  He stated that he had diarrhea for a couple of days and was having increasing pain, especially when sitting.  The patient stated he felt a fever and chills starting the day of presentation.  The patient had erythema and swelling in the posterior anus.  The physical examination revealed erythema and induration in the posterior border of the rectum with no drainage or bleeding.  The patient was to undergo a Computerized Tomography (CT) scan of the pelvis with intravenous contrast to rule out a perirectal abscess.  The patient was noted to have a perianal abscess.  Surgery consultation was requested.  The patient underwent a bedside drainage and was admitted because of involvement of the abscess with the sphincter.  The patient was started on Cipro and Flagyl.  The patient was stabilized and released two days later.

The Milliman Care Guidelines (MCG) indicates that rectal surgeries are performed on an ambulatory basis.  The Ambulatory Surgery Exception Criteria indicate that inpatient care is appropriate for patients, post-operatively, who have the need for a complex surgical approach or situation is anticipated, or when the procedure is not low risk and the patient is at high anesthetic risk.  Inpatient care may also be appropriate for patients who have a post-operative event, condition, or finding that warrants inpatient stay. The patient had a rectal abscess that was drained at the bedside. The patient would have been appropriate for observation status.  Complications were not noted.  The records failed to support that the patient had a necessity for inpatient care.  

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

This patient was admitted for treatment of respiratory syncytial virus positive bronchiolitis after unsuccessful treatment in the Emergency Department.  Of note, as documented at 12:10 the patient placed in Emergency Department physician observation status for respiratory monitoring. Subsequently, the patient was admitted as an in-patient at 16:54. At 17:00, the observation discharge exam revealed: Patient with mild wheezing after albuterol treatments, call placed to the pediatric floor for admission.  Based on the patients reassessment and response to treatment, arrangements made for admission. The patient remained under the direct care of the emergency physician for a total observation time of 5 hours. Care following admission included chest physiotherapy and suctioning every 4 hours, one dose of albuterol, nebulized saline, oxygen saturation checks every 2 hours and feeding on demand with strict intake and output.  The patient remained on room air throughout.
  
The insurer denied coverage for the inpatient hospital services. The denial was reversed.
 
Per Milliman Care Guidelines: P-80, Bronchiolitis, admission is indicated for: Tachypnea, wheeze, or retractions that are severe or persistent after observation care treatment. At the time of admission, there was persistent wheezing despite Emergency Department and observation level of care.
Appeal type: Medical necessity
Decision: Upheld

This patient with past medical history of diabetes, hypertension, asthma and obesity presented with dizziness and chest pain. Patient had a history of a "heart problem" in the past but was unable to clarify what this was. The patient was slightly hypertensive in the ER, remainder of exam was normal. The health plan's determination is upheld.
The patient was treated with IV fluids, repeat labs and monitoring. While the patient was appropriate for monitoring, based on the patient's hemodynamic stability and lack of ischemic changes, this could have been accomplished at a lower level of care status and did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ruptured ovarian cyst
Treatment: Inpatient admission
The proposed inpatient level of care was not medically necessary.

The patient presented with typical signs and symptoms of acute appendicitis, received appropriate treatment initially and follow up imaging ruled out a surgical problem. There were no signs or symptoms of sepsis, heart rate remained normal, and all objective data were normal in less than 24 hours of arrival to the hospital. 

The true diagnosis of a ruptured cyst could have been managed at a lower level of care.

For women with an uncomplicated rupture of an ovarian cyst, observation is recommended rather than surgical intervention. There are no data comparing these two strategies in this patient population, but if there are no concerns about ongoing brisk bleeding or infection or malignancy, the risks of surgery are not warranted.

These patients can usually be managed as outpatients as long as they are hemodynamically stable without a significant drop in hematocrit.   They should return for increased pain or lightheadedness. Oral analgesia is given as needed. Non-hemorrhagic cyst fluid is usually reabsorbed within 24 hours and symptoms typically resolve within a few days. Follicular and corpus luteum cysts account for most of these cases.

Many of these patients will still have a cyst remaining after cyst rupture, since the cyst wall may reapproximate. After observation is complete, these patients should be managed as appropriate. This includes continued surveillance until the cyst resolves and possible surgery at a later time if the cyst is symptomatic or if malignancy is suspected.