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

Diagnosis: Asthma attack.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the proposed inpatient admission is not medically necessary".

The patient is a female with asthma presented to emergency room with wheezing and shortness of breath. Patient had tried and failed outpatient treatment. Patient was found to be in mild asthma exacerbation. In the emergency room, patient was hemodynamically stable and was in mild respiratory distress. With IV steroids and nebulization treatments, patient's wheezing and SOB (shortness of breath) improved partially and patient was admitted to acute in hospital level of care. Patient was continued on IV steroids and nebulizations. Patient's condition improved significantly within 24 hours treatment.

Patient's mild asthma exacerbation improved with emergency room care. The patient was tolerating oral diet and was ambulating. She was discharged home after one day of hospitalization.

The patient's mild asthma exacerbation improved with emergency room care. She was tolerating oral diet and was ambulating. Patient was discharged home after one day of hospitalization. The acute in hospitalization is not medically necessary. The patient could have been safely and effectively treated as an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac Catheterization.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission.  
The denial is upheld.

This is a male patient with a past medical history of hypertension, pre-diabetes, bradycardia and brain surgery due to trauma. The patient was directed to go to the Emergency Department (ED) by his Cardiologist because of a nuclear exercise stress test was positive for inferior wall ischemia. The patient was consulted by Cardiology. He was admitted to the hospital for a cardiac catheterization.  The patient underwent a cardiac catheterization and insertion of a transvenous pacemaker. It was reported that the patient had a right groin hematoma post procedure. The patient was medically stable and discharged.

Based on the review of the medical record and the literature, inpatient admission was not medically necessary for this patient. This patient presented to the hospital for an elective percutaneous revascularization. The patient underwent an attempted revascularization of a chronic totally occluded right coronary artery. Following the procedure, a small right groin hematoma was noted but the patient was ambulating and was discharged the following day.

Several researchers have studied the safety of same day discharge following percutaneous intervention and demonstrated that there is no difference between patients that are discharged on the same day as compared to patients admitted to the hospital.1-4   The current expert consensus from the society of cardiovascular angiography and interventions support that this patient's treatment could have been provided at a lower level of care.4  In conclusion this patient could have been treated at a lower level of care.

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

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

Diagnosis: Respiratory Syncytial Virus, Bronchitis

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a young male patient with a history of pre-term birth via C-section; it was reported that post delivery he spent several days in the hospital on a ventilator for treatment of respiratory distress. The patient presented to the Emergency Department (ED) for complaints of fever and cough for a couple of days. His presenting vital signs were: a low grade fever of 100.1F, heart rate of 152, and respiratory rate of 29. An examination was performed that revealed the patient to be alert, responsive, latching well, his oxygen saturation was 100% on room air, however, rhonchi was noted on his chest exam. The patient's white blood cell (WBC) count was normal at 5,600 and RSV antigen was positive. The patient was treated with albuterol nebulizer, Tylenol, and intravenous (IV) fluid. He was medically stabilized and discharged home. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. There was no medical decision making recorded in the ED chart that could justify for this patient's admission to inpatient care. All that was stated was "cough fever x3 days, congestion." The patient's admission respiratory rate was 22 breaths/min. There was no change in activity, or clinical signs of apnea or sepsis. In assessment of an infant with bronchiolitis, the presence of a normal respiratory rate suggests that the risk of significant viral or bacterial lower respiratory tract infection or pneumonia is low. In this case, this patient's respiratory rate mostly ranged between 28 and 32, and occasionally touched 40, which is expected in an infant with bronchiolitis. Severe adverse events, such as ICU admission and need for mechanical ventilation are uncommon among children with bronchiolitis and observation at home is optimal for the majority of infants with RSV bronchiolitis.1 Moreover, a large multicenter study found no association between the specific viral agent and risk of apnea in bronchiolitis. 2

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

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

Diagnosis: Hydronephrosis.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with history of multiple urinary tract infection (UTI), ovarian cysts, obstructive hydronephrosis due to ovarian cyst status post (s/p) right nephrostomy tube placement with subsequent removal and status post right stent placement with subsequent removal a few weeks prior to presentation. The patient presented to the Emergency Room (ER) with complaints of sharp right lower back pain. 
The patient's presenting vital signs were: blood pressure 116/79, pulse 96, and temperature 99.4 F. A computed tomography (CT) urogram was done that showed a masked right hydroureteronephrosis since the stent removal, and right sided cortical thinning. An ultrasound was performed that revealed severe right hydronephrosis, there was no stone visualized. Laboratory work up was performed that revealed white blood cell count (WBC) 10,900, urinalysis small blood, few bacteria. A computed imaging (CT) scan also showed severe right hydroureteronephrosis, with no obstructing stone. The patient was given intravenous (IV) fluids, IV morphine and the patient was admitted with a diagnosis of hydronephrosis. Urology, OBGYN was consulted. GYN had no treatment recommendations. Urology advised a right nephrostomy tube placement. The patient underwent a right nephrostomy tube placement. The following day the patient had a right stent was placed with the removal of the nephron tube. Her post procedure medication included intravenous (IV) antibiotics for treatment of a UTI and Ketorolac for pain management. The patient was medically stabilized and discharged home.  

Per MCG Health (23rd) Urologic Disease GRG, the patient fails to meet clinical indications for admissions to inpatient care. 

As per MCG Health (23rd) General Criteria: Observation care, the patient meets several guidelines for observation care. These include:

1)	Diagnostic Evaluation Needed
2)	Acute treatment response evaluation needed
3)	Abnormal finding (form lab test, imaginary, exam) prompting significant concern that requires immediate following assessments 30 as to finalize diagnosis or at least rule out those conditions that cannot be followed and treatment in the outpatient setting.

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

The inpatient hospital stay is not considered medically necessary for this patient.

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

Diagnosis: Seizures
Treatment: Inpatient admission
Decision: Upheld

The patient is a female who was brought to the emergency by ambulance after having a seizure while at school. The seizure was witnessed and noted to last four minutes. The patient reported a flash before her eyes prior to the event and she complained of a headache afterwards.  The seizure was associated with tongue biting and bladder incontinence. The event occurred while the patient was running outdoors during gym class and she started to see black dots. She stopped and held onto a rail but the next thing she knew she woke up in the nurse's office and was told she had a seizure.   

The patient sustained a breakthrough seizure after having past history of one prior seizure. The patient was described as clinically stable with no postictal deficits, no vital signs instability and no signs of increased intracranial pressure. Due to the history of two seizures, the patient's clinical scenario was of epilepsy (seizure disorder). Antiepileptic medication was introduced. Considering that the patient was clinically stable, with no recurrent seizures, no deficits, no status epilepticus and no distress, and did not require any intravenous therapies, the patient could have been managed at a lower level of care and did not require acute inpatient services. The services required such as advanced neuroimaging/MRI, EEG, neurological consultation could have been performed at a lower level of care. Acute inpatient admission after an uncomplicated breakthrough seizure is not considered to be a standard of practice in the position statements of the American Academy of neurology or in any practice parameters. Typically, patients after breakthrough seizures are managed on an outpatient basis, after initial stabilization and after the antiepileptic management established or appropriately adjusted. Therefore, the proposed treatment is not medically necessary in this patient's case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Perirectal Abscess.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was overturned.

This is a male patient with a history of a perirectal abscess that has required multiple incision and drainage procedures. The patient presented to the Emergency Department (ED) with right-sided gluteal collection peri-anally location. A computed tomography (CT) scan was performed that revealed a perianal abscess; the abscess collection was encapsulated and was almost 7 x 4 x 2 1/2 cm in size. The patient's pain was rated 9 out of 10 in severity. Surgery was consulted. The patient received intravenous (IV) antibiotics underwent an incision and drain (I&D) of the abscess. The patient was discharged.

In a patient with acute ischiorectal abscess, there is a risk of local spread, and an abscess of this size and location should not be treated as an outpatient, especially considering the patient's extreme discomfort and delay in seeking treatment for this episode. There was also a possibility that the abscess would necessitate placement of a drain for a period of time. Development of chronic fistula is very common if definitive treatment is not instituted emergently. The fact that the patient was afebrile and without any leukocytosis should not have a bearing on the decision on the patient's course of treatment, because anatomically localized infections may not be accompanied by fever or leukocytosis. The procedure that this patient underwent was examination under anesthesia and incision and drainage, which requires at least a short stay in the hospital. The patient also required initial parenteral antibiotic therapy because of the size and the severity of the abscess collection. Thus, inpatient admission was medically necessary for this patient.

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

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

Diagnosis: Schizophrenia.

Treatment: Continued inpatient mental health stay.

The insurer denied the continued inpatient mental health stay.

The denial was upheld.

This is a male patient who was admitted to inpatient mental health treatment due to psychotic symptoms that included command auditory hallucinations telling him to jump off train tracks, paranoid delusional thinking, poor activities of daily living (ADLs), depressed mood, hopelessness, poor appetite, noncompliance with medications, and substance us (i.e. cannabis and K2 spice). The patient reportedly had recent homelessness, and had multiple past psychiatric hospitalizations. The patient was admitted and was treated with Risperidone and Trazodone.  The patient was stabilized and discharged to a men's shelter. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  In this case after several days the patient had no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability.  

Several days into the patient's admission it was reported that the patient denied suicidal or homicidal ideation, had no hallucinations or delusions, no behavioral issues, and that he was compliant and cooperative.  Notes at that time reported that the patient denied hallucinations, delusions, suicidal or homicidal ideation. Continued dated notes through his discharge reported that the patient had no hallucinations or delusions, denied suicidal or homicidal ideation, was cooperative and had goal directed thought process. His mood was good, and that he had no hallucinations or a delusion, denied suicidal or homicidal ideation, and was cooperative. Several days after his admission the patient had no reports of acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting as of then or that could not be achieved in a less restrictive level of care as of then. Thus, continued inpatient mental health stay was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission continued inpatient mental health stay should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Pharmacy/Prescription Drugs

Diagnosis: Dermatitis
Treatment: Dupixent
The insurer denied Dupixent. 
The health plan's determination is upheld.

This is a female with atopic dermatitis, and peeling skin syndrome. She has tried topical steroids. Her sister has done well on Dupixent. Dupixent is being requested and is under review.

Dupixent Syn 300 is not medically necessary for this patient.

The patient is not at least 12 years old. Dupixent is indicated for treatment of moderate-to-severe atopic dermatitis not adequately controlled with topical prescription therapies in patients age 12 and older.

The safety and efficacy of Dupixent was established in three randomized, double-blind, placebo controlled pivotal studies. The populations in these trials included adults that had atopic dermatitis for at least 3 years and had involvement of 10% of the body surface area. The study entrants were also previously uncontrolled by topical therapies. SOLO-1 (n=671) and SOLO-2 (n=708) evaluated Dupixent as monotherapy, while CHRONOS (n=740) evaluated Dupixent as combination therapy. 

In all studies, the primary endpoint was a score of 0 (clear) or 1 (almost clear) on the Investigator's Global Assessment (IGA) and a reduction of  2 points from baseline to week 16. In SOLO-1, the primary endpoint was met in 38% of subjects in the Dupixent group versus 10% of subjects in the placebo group (P< 0.001). In SOLO-2, the primary endpoint was achieved in 36% of subjects in the Dupixent group versus 18% in the placebo group (P< 0.001). 

In week 16 of the CHRONOS trial, 38.7% of Dupixent subjects met the primary endpoint versus 10% of those treated with placebo (P< 0.001). At week 52, similar results were reported for the CHRONOS trial. 

At this time, Dupixent is not medically necessary for this patient as the safety and efficacy in patients younger than age 12 have not been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer 
Treatment: Oncotype DX
The insurer is denied coverage for Oncotype DX. 
The denial is upheld.

This is a male patient who was diagnosed with prostate cancer. The patient's prostate specific antigen (PSA) was 4.69, and the patient's prostate biopsy revealed Gleason 3+3 prostate cancer in 2/12 cores, clinical stage T1c. The patient had Oncotype Dx PCA testing done that revealed that the patient had a GPS score of 21, indicating individual very low risk.

While new American Society of Clinical Oncology (ASCO) guidelines and also National
Comprehensive Cancer Network (NCCN) guidelines indicate that men with low risk or favorable intermediate risk may consider the usage of Oncotype Dx or other gene expression tests, NCCN guidelines also note the absence of randomized prospective trials. The American Urological Association (AUA) guidelines are more guarded or negative regarding the usage of gene expression tests, stating that "tissue based genomic biomarkers (such as Oncotype Dx) have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow-up". The impact of tissue based gene expression tests, such as Oncotype Dx, on clinical practice and long-term patient outcomes remains to be empirically demonstrated prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking. Thus, the Oncotype Dx test was not medically necessary for this patient.

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

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

Diagnosis: Polymyalgia Rheumatica, Pain 
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) with right wrist pain, diffuse pain, weakness, fever and abdominal pain. The patient's exam revealed swelling and tenderness in the right wrist and hand as well as shoulder girdles and back. The patient's left ankle was noted to be tender. The patient's abdomen was soft. The patient's vitals signs were stable, and her temperature was 100.5. The patient's white blood cell (WBC) count was 12k, erythrocyte sedimentation rate (ESR) was 54, C-reactive protein was 90.8, and hemoglobin was 11.8. The patient's urinalysis showed trace leukocytes. The patient's computer tomography (CT) scan of the abdomen and pelvis showed a 7 mm pulmonary nodule. The patient received pain medications and was admitted for pain control and evaluation of weakness. There was concern for a septic wrist. Orthopedics and Rheumatology were consulted. It was determined that the patient had polymyalgia rheumatica (PMR). The patient was given low-dose oral steroids and rapidly improved. The patient was afebrile throughout the admission, and her leukocyte count was normal. 

Based on the review of the medical record, the patient's clinical picture was not one of septic arthritis. The patient had chronic pain that had worsened over a 10-day to 2-week period. There was polyarticular arthritis, minimal fever and one slight elevation of temperature. The patient was seen by Orthopedics and there was no concern for a septic joint. The workup for rheumatologic etiology could have been done as an outpatient. Polymyalgia rheumatica (PMR) is typically treated as an outpatient. Based on the review of the MCG guidelines for Musculoskeletal Diseases, inpatient admission was not medically necessary for this patient. 

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

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

Diagnosis: Chronic right transfemoral amputation.
Treatment: L5999LTx1 3B5X3 (Genium X3) - Adaptive microprocessor-controlled swing and stance phase prosthetic knee.
The insurer denied the L5999LTx1 3B5X3 (Genium X3) - Adaptive microprocessor-controlled swing and stance phase prosthetic knee. 
The denial is upheld. 

No, the L5999LTx1 3B5X3 (Genium X3) - Adaptive microprocessor-controlled swing and stance phase prosthetic knee is not medically necessary.

The patient is a male with a history of chronic right transfemoral amputation.  He is a K4 level ambulator.  He has been using a prosthesis with a C-Leg 4 microprocessor knee.  The current prosthetic knee is in a state of disrepair.  It is unable to be repaired and out of warranty.  He has been using a loaner prosthetic knee.

A replacement microprocessor knee is waterproof and submersible (a Genium X3 knee) has been requested for coverage, as the patient is exposed to inclement weather and water submersion in the course of his work.  He is also an avid outdoorsman, involved in activities such as hunting, fishing, boating and driving an all-terrain vehicle in wet conditions.

The proposed waterproof/submersible prosthetic knee is not a medical necessity, i.e., it is not required for performing mobility-related activities of daily living or instrumental activities of daily living.  He can perform his mobility-related activities of daily living or instrumental activities of daily living using a plan-approved prosthesis, e.g., a C-Leg 4, which would is, notably, weatherproof, albeit not submersible.