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

Diagnosis: Abdominal pain  
Treatment: Inpatient hospital admission  

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

This patient is a female who presented to the Emergency Department via ambulance complaining of abdominal pain.  The patient's past medical history is significant for immunocompromised disease as well as other comorbidities, such coronary artery disease, anxiety, chronic pancreatitis, asthma, and end-stage renal disease on hemodialysis.  The patient was noted to have been admitted recently for abdominal pain for several days and was found to have elevated potassium.  During that inpatient stay, the patient underwent a paracentesis for her ascites.  The patient reported that since discharge from that hospitalization, the patient continued to experience epigastric pain as well as nausea and abdominal distention.  The patient noted that the abdominal pain was so severe that she missed her dialysis. Upon physical exam the patient was in mild distress.  The patient had tenderness to palpation at the epigastrium and slight distention of the abdomen.  It was recommended that the patient be admitted, and undergo her dialysis treatment the following morning.  The patient also underwent esophagogastroduodenoscopy (EGD), which revealed a small hiatal hernia and erythematous mucosa in the antrum.  Biopsies were taken.  Based on multiple consultations, the patient's care was adjusted and treatment was continued without significant adverse events.  The patient was discharged.  

The patient presented with at least three different organ systems affected.  The patient had renal failure, liver failure and heart failure.  Based on literature review, the presence of abdominal pain in the setting of decompensated liver disease and ascites warrants exclusion of spontaneous bacterial peritonitis (SBP).  In the setting of multiple co-morbidities such as this patient, the increased white blood cell (WBC) count associated with SBP may not be apparent, and requires further evaluation.  With patient's elevated creatinine of 9 in the setting of hyperkalemia, this patient could have been experiencing worsening hepato-renal syndrome.  Literature indicates that acute on chronic liver failure with multiple organ system failures is associated with high mortality.  Thus, due to this patient's complex medical history and involved clinical presentation, inpatient admission was medically necessary to treat this patient's medical condition.  
The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.  

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

Respiratory System
Inpatient Hospital

This is the case of a male who presented to the emergency department (ED) with a 2 week history of green nasal discharge. Additional symptoms included decreased oral intake and cough. There was no history of fever, vomiting, diarrhea, or other illness.
Vital signs were temperature (T) 98.8 Fahrenheit (F), heart rate (HR) 115, respiratory rate (RR) 24, and oxygen (O2) saturation of 98% on room air. Physical exam was reported as normal eye, neck, cardiovascular (CV), gastrointestinal (GI), and respiratory systems. Labs showed white blood cell (WBC) count=7.3 with 28% segs, 59% lymphs; hemoglobin (Hgb)=11.5; platelets (Plt)=303. Electrolytes were normal, Flu and respiratory syncytial virus (RSV) testing were negative. Chest x-ray showed perihilar linear opacities consistent with viral etiology or reactive airway disease. The patient was given amoxicillin, Benadryl, and Robitussin. He was admitted to the hospital for further management, given his duration of symptoms and poor oral intake.
Upon arrival to the inpatient floor the patient was noted by nursing to have thick yellow nasal secretions and bilateral wheezing with harsh cough. Saline lock was maintained, the patient was started on albuterol treatments and continued on amoxicillin for presumed pneumonia. The patient remained afebrile during his hospital stay, with normal respiratory rates and O2 saturation of 95-100% on room air. He was discharged home 2 days later with improvement in symptoms. At issue is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

Based on the medical documentation provided, this inpatient hospitalization was not considered medically necessary.
This patient presented with acute upper respiratory illness, normal vital signs, and normal physical exam documentation in the ED. In addition, he had normal blood work and negative RSV/flu testing, plus a chest x-ray consistent with viral pattern. The patient received antibiotics and other medications which did not require an inpatient stay. Therefore, according to the medical documentation provided, this patient's illness could have been managed at a lower level of care status. There is insufficient evidence to warrant inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a Class I occlusion with an appropriate overjet and a slightly deep bite. The maxillary arch has some spacing, and the mandibular arch has some crowding. The patient's family provided a note from a speech pathologist stating his dental alignment is causing speech problems. He was treatment planned for 24 months of orthodontics to correct his malocclusion. At issue is the medical necessity for braces and monthly visits.

The health plan's determination is upheld. There is no medical reason to correct his mild crowding with braces. The patient does have a mild deep bite, however, that alone is not a medical necessity to treat. Regarding his malocclusion affecting speech, the research shows that there is a correlation between anterior open bites and speech problems, [1] but the patient does not have an anterior open bite. The research does not support the conclusion that orthodontics will correct his speech. There is no peer reviewed literature provided supporting an overbite causing speech issues. Despite an exhaustive literature search, I could find no peer-reviewed research in support of orthodontics improving speech in a deep bite patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review. The patient has a history of chronic B lymphedema and HTN (hypertension). He presented to his PMD with two days progressively worsening LLE (lower left extremity) rash and hypotension. His physician then referred the patient to the ER. The patient had subjective fever and chills.

In the ER, the patient's vitals were as follows: T (temperature) - 97.9, P (pulse) - 72, RR (respiration rate) - 18 (increase to 25), BP (blood pressure) - 93/49 (decrease to 88/57). On general examination, the patient was noted to be NAD (no acute distress). Examination of his chest, CVS (cardiovascular system), and abdomen were normal. Examination of his skin revealed erythema extending from proximal leg to distal leg, no crepitus.

The patient's labs were as follows:
WBC (white blood count) - 9.7 (23% bands)
Hg (hemoglobin) - 13.4
Hct (hematocrit) - 39.2
Plt (platelets) - 105 (low)
Na (sodium) - 133
K (potassium) - 7.7 (hemolysis)
Cl (chloride) - 101
CO2 (carbon dioxide) - 26
BUN (blood urea nitrogen) - 40
Cr (creatinine) - 1.9

The patient was thought to have cellulitis and sepsis. He was started on IV ceftriaxone and doxycycline, and admitted. He improved after a day and was discharged on PO (oral) antibiotics.

The patient meets initial criteria for IV treatment and admission for cellulitis given by the Infectious Diseases Society of America (1), as he had systemic signs of infection (elevated respiratory rate, low blood pressure, bandemia). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure Activity  
 
Treatment: Inpatient Admission  

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

This is a female patient who presented to the Emergency Department (ED) after having a witnessed seizure at school causing her to hit her head. It was reported that by the time the patient had arrived to the ED she had returned to her baseline.  She reported having a similar episode several months prior to presentation. On physical exam it was noted that she had sustained open laceration to her head with a small amount of blood; the site was treated with sutures.  The physical examination revealed the patient was in no apparent distress.  Neurology consulted on the patient, there were no neurological deficits noted.  A computed tomography (CT) of the head was performed which was negative for a fracture, mass, hemorrhage, or infarct.  Laboratory studies did not reveal any significant abnormalities. She was started on Keppra.  She experienced no further seizure activity and was discharged home.  

According to the MCG the patient is recommended for admission to inpatient services when there is evidence of hemodynamic instability, a complex febrile seizure, status epilepticus or repetitive seizures that are not controlled with emergent treatment, there is evidence of a brain disorder requiring monitoring or intervention, there are cardiac arrhythmias of immediate concern, new focal neurologic deficits, or altered mental status and is severe persistent.  Within the documentation none of the above is noted.   

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

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

Diagnosis: Preterm Contractions 

Treatment: Inpatient Admission 

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

This is a female patient G3 P2 who presented to the hospital with complaints of cramping, contractions, and pelvic pressure. She denied complaints of vaginal bleeding or fluid leakage. On exam it was noted that her cervix was 10 cm dilated and 50% effaced. She received intravenous (IV) magnesium and betamethasone. She experienced no cervical changes and she was discharged home. 

This patient was complaining of contractions. Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. Did this patient have preterm labor? During this admission, there was no documentation of any cervical changes. So the patient was not in preterm labor. 

This patient could have been observed in labor and delivery, received intravenous (IV) fluid and then re-evaluated a few hours later. If upon re-evaluation no cervical changes occurred, then the patient could be sent home. If cervical changes did occur, then the patient would be admitted for tocolysis and further management. 

Please note that neither the patient nor the fetus were in any jeopardy. There was no evidence of active bleeding and vital signs were stable. The fetal heart rate was reassuring. There was no evidence of ruptured membranes. 

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

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

Diagnosis:  Pulmonary
Secondary:  COPD
Treatment:  DME
The patient has a medical history of oxygen dependent severe chronic obstructive pulmonary disease (COPD).  A home ventilator is requested by the patient's provider.  The health plan's determination of medical necessity is upheld in whole.  The home ventilator is a volume control and pressure control ventilator capable of invasive and non-invasive ventilation.  As per the clinical documentation, the patient has chronic respiratory failure secondary to oxygen dependent severe chronic obstructive pulmonary disease (COPD) with persistent hypoxia and hypercapnia.  Patient has evidence of hypoxia as she requires 24-hour oxygen supplementation to keep her oxygen saturation >88%, but there is no documentation on arterial blood gas of hypercapnia (elevated PCO2 >=52 mmHg).  Also, there is no documentation that sleep apnea and treatment with a continuous positive airway pressure device (CPAP) has been considered and ruled out.  Therefore, based upon the clinical documentation, the member does not meet medical necessity criteria for the home ventilator at this time.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Hypothyroidism 
Treatment:  Formulary exception for Tirosint 

The health plan should cover the formulary exception for Tirosint. 

The patient is a female diagnosed with hypothyroidism.  This request is for Tirosint.  As reported, the patient has history of using Synthroid, which she did not tolerate.  Tirosint is the only gel capsule form of levothyroxine without any filler. 

Tirosint is a brand name of levothyroxine.  The patient is reported to have hypothyroidism.  Tirosint is FDA approved for the treatment of hypothyroidism [1].  As with other forms of levothyroxine, it is effective in the treatment of hypothyroidism [2, 3].  The patient did not tolerate levothyroxine, due to the filler that is present in the tablet.  The formulary alternatives would also not be appropriate for this reason.  The requested medication is the only levothyroxine formulation without filler.  The request is appropriate, and the health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioblastoma Multiforme
Treatment: Cancer treatment- Electric Field Therapy

Summary: This patient has a history of glioblastoma multiforme (GBM) and bladder cancer. The patient underwent resection of a mass in the right frontal lobe in 2018. The patient was seen for initial neuro-oncology consultation. The treatment plan included focal radiation therapy and concurrent temozolomide (TMZ).  Subsequently in 2018, the patient was seen for neuro-oncology follow-up. It was noted that he would complete radiation therapy the following week. The efficacy of Optune in the adjuvant treatment setting for GBM was discussed. At his follow-up visit, the patient's follow-up magnetic resonance imaging (MRI) scan was stable. The treatment plan included initiation of TMZ. The Optune device was discussed. At the patient's subsequent follow-up visit, he was tolerating Optune without difficulty.

The insurer denied coverage for Electric Field Therapy as not medically necessary. The denial was reversed.

Per the National Comprehensive Cancer Network (NCCN) Guidelines, preferred adjuvant treatment regimens for glioblastoma include standard brain radiation therapy and concurrent TMZ and adjuvant TMZ with or without alternating electric field therapy. The submitted documentation supports newly diagnosed glioblastoma, status post resection and radiation therapy.  Optune was to be utilized along with TMZ. This is consistent with standard of care for the patient's condition. Therefore, the requested Electric Field Therapy is considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left renal colic
Treatment: inpatient admission
The inpatient admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  He was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for instability.  Following admission, there were no unstable vital signs reported.  The patient did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, or severe vomiting.  Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with cough and shortness of breath. Tachycardia, tachypnea, elevated blood pressure and 90% room air oxygen saturation were noted at presentation. Physical exam was significant for respiratory distress. Lab data was significant for leukocytosis. Partial pressure of oxygen was 98 millimeters of mercury on initial venous blood gas, which decreased to 52 on repeat. The patient required ventilatory support with bi-level positive airway pressure. The health plan's determination is overturned. 
The need for ventilatory support and persistence of respiratory distress and hypoxia despite emergency department treatment meets medical necessity for inpatient level of care. The patient was at risk for worsening respiratory failure, intubation, and invasive mechanical ventilation in the absence of aggressive care and monitoring that was outside the scope of observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left leg cellulitis 
 Treatment: Inpatient hospital services 

The insurer denied coverage for inpatient hospital services. The denial is reversed. 

This patient is a female with a past medical history significant for thyroid cancer status post thyroidectomy, cellulitis, and a methicillin-resistant staphylococcus aureus (MRSA) infection who presented to the Emergency Department with complaints of worsening left leg swelling and pain. 

Vital signs on presentation included a temperature of 97.8F, a blood pressure of 115/81, a pulse of 76, a respiratory rate of 18, and an oxygen saturation of 98% on room air.  Laboratory results included a white blood cell (WBC) count of 11.3, hemoglobin of 13.0, a hematocrit of 41.6, a lactate of 0.8, a creatinine of 0.8, and glucose of 100. 

The patient was started empirically on intravenous antibiotics (vancomycin and cefazolin) for left leg cellulitis.  A Doppler of the lower extremity was negative for deep vein thrombosis (DVT). Infectious Diseases consulted.  Blood cultures were negative.  The patient remained afebrile and hemodynamically and clinically stable.  She was discharged to continue follow-up as an outpatient on oral antibiotics.

According to documentation, the patient was admitted for a left leg cellulitis.  She was otherwise afebrile and hemodynamically stable.  Laboratory results were only notable for a mildly elevated WBC count.  The patient apparently was treated with dual oral antibiotic therapy as an outpatient without improvement.  Based on documented failure of outpatient intervention in a high-risk patient with recurrent infections including MRSA, the hospital admission for intravenous antibiotics was medically necessary.  

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.  

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

Diagnosis:  Sepsis
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was reversed.

This is a female patient with a medical history of immunocompromise, asthma, hyperlipidemia, osteoarthritis, and status post bilateral abdominal panniculectomy/ excision.  She presented to the Emergency Department (ED) with complaints of fever, chills, diarrhea, and weakness.  Her presenting vital signs were Temperature 100.1 F, Blood Pressure-104/76, Pulse-141, and Respiratory Rate-19.  A laboratory work up revealed white blood cell (WBC) count-16.4, hemoglobin (HGB)-10.9, hematocrit HCT-33.2, potassium-3.1, creatinine-0.96, and glucose-158.  She was treated with intravenous IV antibiotics vancomycin and Zosyn for possible sepsis.  Stool was tested for C Diff, which was negative.  A computed tomography (CT) of the abdomen was performed that was negative or any anomalies.  She developed a rash; dermatology was consulted and biopsies were performed.  She remained afebrile and hemodynamically stable and was discharged home with outpatient instructions.  

According to documentation, patient presented with fever and gastrointestinal symptoms of unclear etiology.  She presented with low-grade fever (100.1 F), tachycardia (141), multiple laboratory abnormalities including elevated WBC (16.4), anemia, elevated glucose, and low potassium (3.1).  Based on these abnormal findings in a high-risk patient with a history of immune compromise and recent surgical procedure, hospital admission was medical necessary for intravenous antibiotics and additional diagnostic evaluation. 

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

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

Diagnosis:  Abdominal pain
Treatment:  Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female.  She presented with sudden onset of abdominal pain for two hours.  She had a previous diagnosis of gallstones.  She denied fever, nausea, or vomiting. 

The patient's vitals were stable in the ED, with normal BP (blood pressure) and heart rate.  Her abdominal exam was significant for RUQ (right upper quadrant) tenderness.  Her ultrasound was positive for gallstones, no thickening, no fluid and a (-) Murphy's sign.  Her WBC (white blood count), Bilirubin and Alk Phos were normal, with a slight elevation of both ALT (alanine aminotransferase) and AST (aspartate aminotransferase).  

The patient was stable for discharge per the ED; however, she demanded and made known to the surgical team that she wanted surgery.  The patient was made NPO (nothing by mouth) initially, improved, and started on clears.  In fact, the surgical team noted her abdominal pain resolved with no fever, chills, nausea or vomiting.  In addition, her abdominal exam was noted to be soft, non-tender, non-distended without guarding or rebound. 

The patient underwent laparoscopic cholecystectomy.  She felt weak the following day and was given extra fluids.  The patient was deemed stable for discharge.

Acute pain management - During an acute attack of biliary colic, management is focused on pain control.  Pain control can usually be achieved with nonsteroidal anti-inflammatory drugs (NSAIDs).  Opioids are reserved for patients who have contraindications to NSAIDs or who do not achieve adequate pain relief with NSAIDs.

For patients with typical biliary colic and gallstones on imaging who are surgical candidates, elective cholecystectomy is recommended in order to prevent future attacks of biliary colic and complications of gallstone disease.  For those patients whose biliary colic subsides while in the emergency department, follow-up for elective cholecystectomy should be arranged, as emergency cholecystectomy is associated with a higher risk of complications.

Patients are referred for cholecystectomy after an isolated attack of biliary colic even though approximately a third of patients with a first episode of biliary colic will not develop a recurrence within two years.  The rationale for this approach is that some patients may have unrecognized recurrent attacks if the initial attacks were not severe enough to have prompted medical attention.

This patient had biliary colic and not acute cholecystitis.  Outpatient treatment with elective surgery was indicated.  Therefore, the Inpatient admission was not medically necessary.