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

Diagnosis: Thrombophlebitis
Treatment: Inpatient Hospital

Summary: This patient with a past medical history of thrombophlebitis and varicose veins presented to the Emergency Department (ED) for a Doppler sonogram to the right leg. The patient was previously seen in the ED the previous Wednesday. The patient stated that previously she was seen with a blood clot found in the right leg. The patient had an ultrasound performed at that time and was told to return for a second ultrasound. The patient endorsed doing warm compresses on the affected area and was scheduled to undergo an appointment with a vascular physician. On examination, there was firmness noted to the medial aspect of the right lower extremity. The patient underwent a duplex sonogram of the right lower extremity that revealed no evidence of right lower extremity deep venous thrombosis (DVT). There was superficial thrombophlebitis in the right greater saphenous vein at the level of the knee and proximal calf. The patient was considered high risk for conversion to DVT. The patient was started on heparin drip and was admitted for bridging. Enoxaparin injections were started and warm compresses were continued.
  
The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
The medical literature indicates that inpatient admission is indicated for patients who are at high risk for acute complications with DVT if there is evidence of bleeding before anticoagulation, recent surgery, recent gastrointestinal (GI) bleeding, recent ischemic stroke, history of intracranial bleeding, history of active bleeding when anticoagulated or active substance abuse. Inpatient care may also be indicated for patients with limb threatening thrombosis, thrombolysis, pregnancy with delivery planned, or contraindication to outpatient use of medication. The documentation indicated that the patient presented to the ED after previously being seen. The patient underwent a Doppler sonogram to the right leg that revealed superficial thrombophlebitis in the right greater saphenous vein at the level of the knee and proximal calf. The physician was concerned for high risk of conversion to DVT. However, there was no evidence of high risk acute complications such as bleeding before anticoagulation, recent surgery, recent GI bleeding, recent ischemic stroke, history of intracranial bleeding, history of active bleeding when anticoagulated or active substance abuse. There was no evidence of limb threatening thrombosis, thrombolysis, pregnancy with delivery planned or contraindication to outpatient treatment.  Therefore, the patient's condition was appropriate for level of observational care rather than inpatient level care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease, End-Stage Renal Disease
Treatment: Inpatient Hospital

Summary: This patient has a past medical history of hypertension, hyperlipidemia, diabetes mellitus type II, chronic obstructive pulmonary disease (COPD), and end-stage renal disease on hemodialysis.  She has peripheral artery disease and had peripheral stents in 2017 and five total toe amputations in 2017. She has known coronory artery disease (CAD) with prior myocardial infarctions in 2016 and 2017. She now presented for a cardiac catheterization with possible intervention due to a recent positive stress test, which was done as part of a pre-op cardiac risk stratification workup prior to a renal transplant. She states that she is asymptomatic. The patient had an elective coronary angiogram performed during this admission. The report indicated that the left main was normal. There was a calcified 80% proximal stenosis in the left anterior descending (LAD), which went to 0% after percutaneous coronary intervention (PCI). The circumflex showed mild luminal irregularities. There was a calcified 80% proximal lesion in the right coronary artery (RCA), which went to 0% following PCI. There was a calcified 90% mid-lesion in the RCA, which went to 0% following PCI. The left ventricular ejection fraction (LVEF) was 55% with normal end diastolic pressure (EDP) post angiogram. No complications were noted. The patient had dialysis and tolerated the procedure well. She was thought to be stable for discharge home. Arrangements were made for outpatient follow-up.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient was electively admitted to the hospital for a coronary angiogram because of a positive stress test that was noted in a workup that the patient was undergoing for renal transplant. At the time of this admission, the patient was asymptomatic and had no complaints. The diagnostic angiogram was uncomplicated, as was the PCI to the LAD and left circumflex (LCX). The patient's post procedure course was uncomplicated. There was no mention of chest pain or arrhythmia and no mention of elevated troponins or an abnormal electrocardiogram (EKG). The patient's physician stated that she needed inpatient hospital admission because of her diagnosis of unstable angina. There did not appear to be any evidence provided in the history that was consistent with a diagnosis of unstable angina, as defined in the literature that has been cited. This patient's care could have been provided in a less intense setting and this statement is supported by the literature cited. The acute inpatient admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychotic disorder best characterized as schizophrenia or schizoaffective disorder, bipolar type

Treatment: Continued inpatient psychiatric services

Summary:
The patient's continued hospital stay for treatment of an exacerbation of a psychotic disorder (schizophrenia) did require the continued inpatient level services, structure, and monitoring through discharge.  The patient's severity of symptoms, and inability to effectively participate in treatment at a lower level of care, persistent functional impairment, and safety issues related to persistent symptoms of acute psychosis were clinical factors and treatment dimensions that necessitated continued acute inpatient hospital care, structure, and monitoring, as proposed through discharge.  The medication adjustments and safety monitoring together with attention to subsequent care needs and compliance issues, the support of functioning and the continued application of multimodal treatments, as well as assurance of medication adherence, were factors that did warrant the continued inpatient level treatment through discharge; the patient could not have been effectively managed at a lower level of care during the time interval under review.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a diagnosis of invasive lobular carcinoma of the left breast. She is now recently developed recurrence of her invasive carcinoma in the lower inner quadrant of the left breast. 

The health plan's determination is overturned. The proposed health service or treatment Proton Beam Radiation Therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Proton Beam radiation therapy (RT) enables delivery of radiation to the chest wall and regional lymphatics, including the internal mammary nodes without compromise of coverage and with improved sparing of surrounding normal structures. Proton therapy in this case would be beneficial in that the dose to the underlying anterior portion of the heart would be minimized.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient underwent lumpectomy in 2015 for breast cancer. The breast cancer recurred in 2018 and she underwent a lumpectomy again. The patient was treated with adjuvant radiation therapy (RT) using Proton beam. 

The health plan's determination is upheld. The proposed health service or treatment Proton Beam Radiation Therapy is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Proton beam therapy is an emerging technology which has been used in past few years to treat several clinical conditions. However, there is no clinical published data to support its superior clinical outcome compared to other routine 3D CRT or intensity modulated radiation therapy (IMRT) techniques.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has a history of a left breast invasive lobular carcinoma in 2015 where she had lumpectomy only and no adjuvant therapy. The patient now has recurrent left breast lobular carcinoma in 2018. Radiation therapy is recommended to the left breast and chest to decrease her risk of recurrence.

The health plan's determination is upheld. The proton beam therapy is not likely to be more beneficial than any standard treatment or treatments for the insureds life threatening or disabling condition or disease. Proton beam radiation therapy is not considered a standard of care approach of treatment for external beam breast irradiation for invasive carcinomas.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic colitis
Treatment:  Inpatient admission 

Summary:
The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient manifest with self-limited abdominal discomfort and BRBPR (bright red blood per rectum) with nonspecific CT scan findings. There was no vomiting, and dehydration was not apparent from admission lab work. Also, available records do not support there being electrolyte abnormalities, leukocytosis, anemia, nor was there present hemodynamic instability, cardiac arrhythmias of immediate concern, acute renal failure. Vital signs were stable without fever both on presentation and throughout her hospitalization. Neither liver function tests nor inflammatory markers were elevated. Her complaint of discomfort was subjective, with examination showing a non-distended abdomen without rebound, and with normal bowel sounds. The Gastroenterology consultant documented brown stool without blood. No immediate surgery nor GI intervention was planned to warrant acute inpatient care, nor do available records support the need for IV antibiotics. The patient readily tolerated PO medications and nutrition. The criteria for a medical necessary hospitalization were not met such that care could have been rendered at a lower level of service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe, recurrent headache
Treatment: Inpatient hospital admission 

Summary:
The patient presented with thunderclap headache and CT angiogram was consistent with reversible cerebral vasoconstrictive syndrome.  There was no evidence on MRI brain (which was not completed) or neurological examination to support a diagnosis of vasculitis.  She did not have any further testing done.  The diagnostic tests, treatment and monitoring could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever
Treatment: Inpatient Hospital

Summary:  This patient with a benign past medical history presented to the Emergency Department (ED) with complaints of fever, cough, and myalgias after ingesting ecstasy three weeks prior to presentation.  Vital signs on presentation included:  a temperature of 100.1F, a blood pressure of 144/78, a pulse of 89, a respiratory rate of 20, and an oxygen saturation of 99%.  Laboratory values were notable for the following:  a white blood cell count (WBC) of 19.6, hemoglobin of 13.0, a hematocrit of 38.2, a creatinine of 1.33, glucose of 90, an aspartate aminotransferase (AST) of 47, and an alanine aminotransferase (ALT) of 137.  The patient was admitted to rule out infection.  He was empirically started on antibiotics (vancomycin).  A chest x-ray was negative.  The patient remained afebrile and hemodynamically and clinically stable.  He decided to leave the hospital against medical advice (AMA).
  
The insurer has denied coverage for the inpatient hospital admission as not medically necessary.  The denial was reversed. 

According to documentation, the patient presented to the ED with fever and myalgias. He had a low grade fever, and laboratory results showed an elevated WBC (19.6), creatinine, and liver function tests.  In addition to the above abnormalities, the patient was high risk for infectious complications due to a history of drug use (cocaine, ecstasy).  Despite the patient leaving AMA, the hospital admission was medically necessary based on the above findings.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a surgical history of adenoidectomy and tonsillectomy who presented to the emergency department (ED) on 1/1/19 for lower abdominal pain and 3 episodes of vomiting.The patient was admitted and treated for possible urinary tract infection (UTI) with intravenous fluids and antibiotics.

The health plan's determination is upheld. The Inpatient Hospital Admission was not medically necessary for this patient. Further evaluation and treatment could have been performed at a lower level of care. This patient did not have symptoms or a urinary tract infection and did not require intravenous antibiotics. She could have been monitored in the emergency department with repeat labs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, Acute Cholecystitis 
Treatment: Inpatient Hospital

Summary:  This patient was seen in the Emergency Department (ED) for complaints of abdominal pain.  She stated that she did have a cesarean section three weeks prior and was diagnosed with pancreatitis at a different facility.  On examination she had a temperature of 98.0F with a heart rate of 75 beats per minute (bpm).  The patient's blood pressure was 115/45, and her oxygen saturation was 98%.  The physical exam revealed she was alert and oriented and in no acute distress.  The patient was recommended to undergo laboratory and diagnostic studies.  The Computed Tomography (CT) scan indicated that gallstones that were seen on a recent ultrasound were not identified.  There was suggestion of gallbladder wall thickening, and acute cholecystitis could not be ruled out.  The note stated that as air in the bowel can mimic gallstones on ultrasound, a Magnetic Resonance Imaging (MRI) scan was advised.  There was no CT evidence of pancreatitis.  There was mild constipation noted.  The patient was recommended for admission, so she could undergo a hepatobiliary iminodiacetic acid (HIDA) scan.  The patient was also recommended to utilize Zofran as needed.  She was also diagnosed with a urinary tract infection, and it was recommended that she continue antibiotics.  The patient did undergo a HIDA scan, which did not reveal any biliary or cystic duct obstruction.  It was recommended that the patient undergo an elective cholecystectomy.  The patient on exam was noted to have slightly elevated liver enzymes, which continued to trend downward.  The following day, after no significant adverse events, the patient was discharged in stable condition with instructions to follow-up.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary.  The denial was upheld. 

According to current literature, a patient may be admitted for undiagnosed abdominal pain when there are peritoneal signs, hemodynamic instability, severe pain requiring acute inpatient management, surgery is needed that cannot be performed on an ambulatory basis or there is identification of etiology or finding that requires inpatient care.  Within the documentation, the above was not noted.  The patient was recommended for admission after laboratory and imaging suggested the possibility of acute cholecystitis.  However, there was no documentation of why the patient could not have continued observation at a lower level of care.  The documentation did not detail that the patient needed emergent surgery or that there were peritoneal signs present.   Additionally, there was no evidence of hemodynamic instability or severe pain requiring acute inpatient management.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/ Gastrointestinal (Appendicitis)
Treatment: Inpatient Hospital

Summary: This patient with a past medical history of gastritis, cholecystectomy, and thyroid issues presented to the Emergency Department (ED) with symptoms of epigastric/periumbilical abdominal pain. The patient reported having nausea and vomiting. The Computed Tomography (CT) scan that was performed was consistent with acute nonperforated appendicitis. The laboratory studies revealed leukocytosis with a white cell count of 16.0. The patient had an Alvarado score of 5. The patient was placed on nothing by mouth status and was placed on intravenous fluids and antibiotics. The patient was admitted for a laparoscopic appendectomy for acute appendicitis. The patient had localized peritonitis. The patient was stabilized and discharged on the day of admission.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

Milliman Care Guidelines note that patients who undergo an appendectomy with abscess or peritonitis are appropriate for a two-day admission. The patient underwent a laparoscopic appendectomy for acute appendicitis and was noted to have localized peritonitis. The records supported that the patient was stable prior to the procedure. The patient could have been observed prior to the procedure and admitted post-operatively, if necessary. There were no exceptional factors noted. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient complained of dyspnea and was referred for a cardiac catheterization. The patient had a history of coronary artery disease (CAD) with previous stenting, hypertension, diabetes, and hyperlipidemia. On 1/14/19, the patient underwent cardiac catheterization which showed a 70% proximal left anterior descending (LAD) in-stent stenosis which underwent drug eluting stenting. 

The health plan's determination is upheld.The inpatient stay was not medically necessary. The patient had an elective coronary intervention. It was reasonable to observe the patient for several hours after the procedure to assure no bleeding or ischemic events, but this could have been performed as an outpatient or at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for menorrhagia, uterine fibroids, migraine, and iron deficiency anemia who presented to the hospital with a chief complaint of left lower quadrant pain, vaginal pain, weakness, dysuria, nausea and blood tinged stools.
Given concerns for a urinary tract infection (UTI) and anemia, the patient was subsequently admitted to the hospital. She was started on ceftriaxone. 
The health plan's determination of medical necessity of upheld. Her chronic anemia responded appropriately to two units PRBCS transfused. She did not have abnormal imaging. Her UTI  did not require inpatient treatment nor did her pain control.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Language processing disorder, learning disorder, attention deficit hyperactivity

Treatment: Extended outpatient therapy

The insurer has denied extended outpatient psychotherapy. That denial was upheld

This child was seen for a one hour of individual consultation on the date in question to assess the patient's candidacy for therapeutic services.  The patient does have a diagnosis of language processing disorder and specific learning disorder with impairment in reading.  The documentation also indicated that the patient was suffering from Attention Deficit Hyperactivity Disorder (ADHD). 

Per the literature, children with ADHD are usually treated with either medications, behavioral interventions, parent training, school accommodations and interventions, or a combination of these therapies.  Research shows that behavioral therapy is an important part of treatment for children with ADHD.  ADHD affects not only a child's ability to pay attention or sit still at school; it also affects relationships with family and how well they do in their classes.  Additionally, behavioral interventions have shown to be effective for improving language, cognitive abilities, adaptive behavior, and social skills, and reducing anxiety and aggression in children with autism spectrum disorder.  

While behavioral interventions may be appropriate to treat a child with ADHD, the submitted documentation does not provide sufficient evidence that this child needed extended outpatient services to determine the need for further treatment.  It is unclear what the patient's clinical picture detailed at the time of the requested visit.  Several attempts were made to obtain medical records for this case to no avail. Therefore, there was no indication of why the patient would need the requested extended service.
Appeal type: Medical necessity
Decision: Upheld

The patient is requesting a computed tomography (CT) scan of the abdomen pelvis for abdominal pain and bleeding. The appeal information describes that the CT scan was ordered to assess for serious causes of gastrointestinal bleeding. The patient was evaluated the day before the CT scan and reported bleeding.

The health plan's determination is upheld. A CT scan of the abdomen pelvis was not medically necessary in this case. The patient had a report of bleeding with no drop in the hemoglobin. The white blood cell count was normal. The metabolic panel was normal. There was no clinically significant weight loss, bleeding, palpation of abdominal mass. There were no obstructive findings on physical exam.
Appeal type: Medical necessity
Decision: Upheld

The patient received treatment for opioid dependence and withdrawal. The patient initially presented for care on 02/09/19. At that time, the patient had normal vital signs and a urine drug screen that was positive for opiates, cocaine and notably negative for oxycodone and buprenorphine. The patient reported primarily using heroin with last use on 02/08/19 and also using cocaine with last use on 02/06/19. On initial evaluation, the patient reported symptoms of nausea, anxiety, yawning, hot/cold sweats, tremors, irritability, abdominal pain, teary eyes. 

The health plan's determination is upheld. The inpatient detoxification was not medically necessary. The patient had no unstable medical or psychiatric problems during the dates of service and question. He had no suicidal or homicidal ideation, intent, or plan. The patient had no life-threatening withdrawal symptoms. He could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: grade I ganglioglioma with a BRAF mutation
Treatment: Zelboraf 240MG tablet
The Zelboraf is medically necessary.
Vemurafenib is a selective oral inhibitor of the oncogenic BRAFV600 kinase approved globally for the treatment of patients with BRAFV600-mutant metastatic or unresectable melanoma and in the United States for patients with Erdheim-Chester disease. It is known that low grade gliomas which have BRAFV600 mutations will respond to this drug. 
The medical literature has demonstrated the efficacy of the drug in this tumor type and there are no other known effective therapies for this patient.
Appeal type: Medical necessity
Decision: Overturned

This patient with past history of diabetes presented with pain and redness on right buttock. Symptoms began two weeks prior to presentation and were getting progressively worse. CT showed calcified lesion consistent with cellulitis/edema. The patient was started on IV antibiotics and seen by infectious disease specialist. The health plan's determination is overturned in whole.
The inpatient admission was medically necessary and appropriate in this case. The patient met criteria for sepsis upon presentation, and had source of infection. This is potentially life-threatening and an acute level of care was medically necessary.