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

Diagnosis: congestive heart failure
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) with left sided crushing chest pain and shortness of breath for one hour. The patient also reported dyspnea on exertion and orthopnea.
The patient reported that he underwent coronary stent placement. Prior to stent, the patient felt the same symptoms. His past medical history (PMH) was significant for hypertension (HTN), HLD (hyperlipidemia), non-ST elevation myocardial infarction (NSTEMI), coronary artery disease (CAD), congestive heart failure (CHF), atrial flutter, obesity, diverticulitis and kidney stones.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with chest pain after recent stent. His chest pain was similar to previous chest pain, prior to stent, but his troponin was only mildly elevated without significant peak and his ECG did not have ischemic changes. No additional tests, beside serial troponin, was done. No inpatient level of care was indicated based on his chest pain. A lower level of care would be more appropriate.
The patient remained stable and was treated with oral medications. The patient felt to have congestive heart failure (CHF) exacerbation, but it was mild, and treated with intravenous (IV) Lasix with good response. The chest x-ray (CXR) did not reveal significant fluid overload. Because his CHF exacerbation was mild, the inpatient level of care was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic cholangiocarcinoma status-post (s/p) resection
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The patient has a past medical history significant for metastatic cholangiocarcinoma status-post (s/p) resection, chemotherapy, radiation therapy, gastroesophageal reflux disease (GERD), gastritis, and chronic pain who presented to the emergency room with complaints of nausea and vomiting.

Vitals on presentation included: Temperature 36.5 Celsius (C), blood pressure (BP) 115/87, pulse (P) 93, respiratory rate (RR) 18, oxygen (O2) saturation 99% on room air (RA). Laboratory values were notable for the following: white blood cell (WBC) 6.9, hemoglobin (Hgb) 8.7, creatinine 0.5, glucose 95, alkaline phosphatase 1900, total bilirubin (T-bili) 12.6, aspartate aminotransferase (AST) 90, and alanine transaminase (ALT) 141.

The patient was admitted for evaluation of worsening liver function tests. The patient had a biliary drainage tube for 6 weeks that was draining foul smelling fluid. The patient was started on intravenous (IV) antibiotics (meropenem). The patient developed new leg weakness and a stroke code was called. The patient underwent a biliary drain exchange. The patient was discharged to resume home hospice care.  
 
According to medical records, the patient presented with nausea, vomiting, and worsening elevated liver function tests believed to be secondary to a nonfunctional biliary drain versus progression of underlying metastatic cancer. Based on the above findings, in a high-risk patient with terminal end-stage cancer, hospital admission was medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is substantiated
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

Diagnosis: Vomiting
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns for nausea and vomiting. Pertinent history included cyclical vomiting syndrome. Initial vital signs revealed a temperature of 97oF, heart rate (HR) 63, blood pressure (BP) 201/102, respiratory rate (RR) 18, peripheral capillary oxygen saturation (SpO2) 99% on room air. Initial examination documented the patient as alert, oriented, and without peritoneal signs. An electrocardiogram (EKG) did not reveal acute ischemic changes. Initial laboratory testing revealed a white blood cell (WBC) 10.9, Hemoglobin (HGB) 13.0, platelets (Plt) 237, blood urea nitrogen (BUN) 14, Cr (creatinine)1.1, Na (sodium)143, K (potassium)3.8, Lipase 12, Tbil (total bilirubin) 0.4, aspartate aminotransferase (AST) 18, alanine aminotransferase (ALT) 18. Toxicology was positive for TCA (tricyclic antidepressants) only. A chest x-ray (CXR) was unremarkable. The patient was placed in the hospital thereafter with an impression of intractable cyclical vomiting syndrome, sinus bradycardia, and resolved hypertensive urgency. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a documented history of cyclical vomiting syndrome who presented with concerns of nausea and vomiting. Initial examination documented the patient as alert, oriented, hemodynamically stable, and without peritoneal signs. Initial evaluation did not reveal significant electrolyte abnormalities. Treatment plan was largely supportive care. Gastroenterology consulted and recommended outpatient follow-up. Following observation care, diet advancement was tolerated and the patient was discharged. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chest Pain.
Treatment:  Inpatient Admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

The patient is an adult with multiple medical issues including coronary artery disease (CAD), severe anemia with prior upper endoscopy and colonoscopy which revealed a non-bleeding gastric ulcer, anxiety, and depression.

The patient presented to the hospital with complaints of chest pain of 2 days duration. The patient's pain was pleuritic in type and retrosternal and was worse with expiration.

The patient's vital signs were normal and oxygen saturation was 100% (percent). The patient was in no acute distress but was ill appearing. The patient's lungs were clear, heart sounds were normal, and the patient was alert and oriented.  White blood cells (WBC) were 4.8, hemoglobin 6.6, hematocrit 25, troponin negative, and electrolytes were within normal limits. The patient's chest x-ray showed no acute infiltrates, but a computed tomography angiogram revealed a small left lower lobe pulmonary embolus.

This patient had symptomatic anemia without a definitive etiology. The plan was to anticoagulate with short acting medication and also transfuse the patient to a hemoglobin of 8. The patient also needed a work up for anemia. Prior studies had not revealed any active bleeding site. This patient was seen by the gastroenterologist and Capsule Endoscopy was planned for evaluation of the patient's small bowel. As this patient was also being anticoagulated and already had significant and symptomatic anemia, they were at high risk of complications related to bleeding.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatent Hospital Stay.
The determination is overturned.

This is a female patient with abdominal pain and concern for ovarian torsion. She had imaging that showed a 10x6x6 centimeter (cm) right ovarian mass. She was admitted from an outside hospital. The concern was for prolonged torsion and the ovarian cyst- which could represent a tumor. Her lab results were normal except for cancer antigen (CA) 125 which was marginally elevated at 41. The pathology was significant for benign ovarian tissue, hemorrhagic cyst and a benign paratubal cyst. Postoperatively for pain she did receive Morphine, Tylenol and Toradol. At issue is the medical necessity of an inpatient stay.

The hospital stay was medically necessary for several reasons:
1. pain control and nausea control
2. evaluation of the ovary to ensure it was not a tumor
There is only one adult study that has evaluated enhanced recovery after surgery (ERAS) in minimally invasive non- hysterectomy gynecologic cases. In this study, same-day discharge rates only increased by 9.4 percent (%) after ERAS implementation. A major driving factor is post operative nausea (1). Increased same-day discharge did not lead to higher postoperative complications or changes in 30 day emergency department visits or readmissions in patients with enhanced recovery after surgery. (ref 1)
In the pediatric world, the most widely studied same day discharge is with appendicitis (noncomplicated) (2,3)-in these cases early discharge has been shown to be safe and a patient/family satisfier.
However, extrapolating appendicitis to ovarian pathology can be challenging- especially with the concern for a potential malignancy (CA125 was slightly elevated). There is no standard of care supporting discharge for a patient with a large ovarian lesion that has undergone surgery, especially if there was an elevated tumor marker preoperatively. She was given intravenous (IV) fluids postoperatively as well as morphine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pneumonia
treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male child with medical history significant for learning disorder, developmental delay, autism, iron deficiency on supplemental iron, and thrombocytosis on aspirin and followed by Hematology. He presented to the emergency department (ED) with a three-week history of cough, two-day history of eye redness with itching, congestion, several episodes of vomiting, and fever. Vital signs were significant for temperature 38.2, heart rate 159, respiratory rate 22, and 96% saturation in room air. 

The inpatient hospital admission was not medically necessary. This young male with complex medical and developmental history presented with several week history of cough, some congestion and fever and conjunctivitis. Diagnostic testing revealed bilateral infiltrates, confirmation of thrombocytosis exacerbated by infection, and significant leukocytosis. While it was reasonable to monitor him in the hospital initially for stabilization versus decompensation, particularly given the complexity of his condition. But he was overall hemodynamically stable with no need for supplemental oxygen, no significant dehydration, and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 Braces
The insurer denied D8080 Braces.
The denial is upheld.

The patient is an adolescent male with malocclusion of permanent dentition. The boy has moderate upper anterior crowding and severe lower anterior crowding. He has a significant overbite, multiple rotated teeth, multiple retruded incisors, and his molars are in Class I relationship. The request for D8080 Comprehensive Orthodontics was denied coverage by the health plan as not medically necessary. A score of 26 on the Handicapping Labio-Lingual Deviation Index is required. The patient's malocclusion received a score of 20 points. The denial is being appealed.

The requested braces are not medically necessary.

Medical necessity for braces requires a severe handicapping malocclusion, which is determined by use of the Handicapping Labio-Lingual Deviation (HLD) Index or auto-qualifiers, as well as other indices. Upon review of the documents provided by the patient's orthodontist, there is no evidence that the patient has any auto-qualifiers or has any difficulty eating, breathing, swallowing, or speaking for which orthodontic treatment would be needed. While the patient does have a deep overbite, the photographs provided do not show evidence of severe soft tissue damage because of impingement. This is not possible to determine without orthodontic models or images of models. Therefore, the requested braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is a teenage female. She presented to the emergency department (ED) after a paroxysmal episode. Medical records note that the patient was helping her mom clean at home when she suddenly became dizzy and lightheaded, her vision went black, and she fell into mom's arms shaking. She denied loss of consciousness (LOC), reporting she could hear what was around her, but she could not speak. There was no precipitating injury, though she did report a headache that day. After the event she reportedly could not speak for 30 minutes. She has a history of a similar episode at age five that was due to hypoglycemia.
At presentation, the patient was afebrile with normal vital signs. Her physical examination also did not show any abnormalities. Laboratory workup, including complete blood count (CBC), 
electrolytes, liver function studies (LFTs), and finger stick glucose, was normal. Electrocardiogram (ECG) was normal. She was diagnosed with a syncopal episode versus seizure with post-ictal phase and admitted to the inpatient pediatric team. Pediatric neurology and pediatric cardiology were consulted. The patient was placed on a continuous cardiac monitor. The health plan denied coverage of the inpatient admission f. The denial is being appealed.

The Inpatient admission was not medically necessary.

According to the guidelines, admission is indicated when certain criteria are met. These criteria include one or more of the following: hemodynamic instability, febrile seizure including additional criteria, status epilepticus, brain disorder that requires monitoring or intervention available only at inpatient level of care, etiology that requires monitoring or intervention available only at inpatient level of care or that persists despite observation care, altered mental status that is persistent, new focal neurologic deficit (e.g., post seizure), metabolic disorder, recurrent seizures (i.e., during emergency department or observation care) and one or more of the following: patient not known to have a seizure disorder; recurrent seizure is of a different seizure type than previously known seizure disorder; patient with a baseline of infrequent seizures; outpatient antiepileptic regimen cannot be established; cerebral bleeding, hydrocephalus, or vasospasm monitoring, increased intracranial pressure or cerebral edema monitoring. The patient in this case did not meet any of the above criteria. She was hemodynamically stable, did not have a febrile seizure, brain disorder, status epilepticus, persistent altered mental status, new focal neurological deficit, metabolic disorder, or recurrent seizures. In addition, she did not require antiepileptic treatment. Thus, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypoglycemia
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

This is a young female diagnosed with hypoglycemia, Polyuria, and Polydipsia. The patient has a history of sickle cell trait and milk protein allergy. The patient presented to the emergency room (ER) due to increased urination and thirst for four days. In the ER, Accu-Check on arrival was 67 and then 63. After drinking juice, glucose was 166 and then 63.

The inpatient hospital admission is medically necessary.
The patient is a young female who presented with spontaneous hypoglycemia of unclear etiology. Infants with hypoglycemia who do not have diabetes and are not on insulin are at high risk for seizure and an evaluation and monitoring is warranted in order to rule out serious causes of hypoglycemia such as glycogen storage disease, Ketotic hypoglycemia, adrenal insufficiency or hyperinsulinism. The patient presented with severe hypoglycemia to the 50s in the setting of illness. Intravenous fluids and treatment followed by observation to determine if the hypoglycemia is recurrent is consistent with generally accepted standards of medical practice. The patient could not have been safely discharged from the emergency room. Therefore, the inpatient hospital admission is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumothorax
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult female. She presented with multiple right rib fractures, pulmonary contusion, and pneumothorax. She was admitted to the hospital.

The Inpatient admission was medically necessary.

Multiple rib fractures with pulmonary contusion and pneumothorax is a very serious trauma with a mortality of 10 percent (%). Admission for pain control, pulmonary toilet, and monitoring for complications is essential. Therefore, this admission and hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder, diabetes mellitus. 
Treatment: Consumer Directed Personal Care Aide to 35 Hours per Week. 
The insurer denied: Consumer Directed Personal Care Aide to 35 Hours per Week. 
The denial is overturned. 

The patient is an adult female with a history of general debility due to anxiety and bipolar disorder. The request was for Consumer Directed Personal Care Aide to be increased from 21 hours per week to 35 hours per week based on Uniform Assessment System (UAS) of 4 months ago. The health plan denied the request because the request did not have enough information to determine if the service is medically necessary. In addition, the patient can perform some instrumental activities of daily living (IADLs). The additional hours requested are because of the patient's chronic medical conditions including anxiety and diabetes mellitus, and to help with her activities of daily living. A review of the records showed that the patient has multiple chronic medical conditions including anxiety, bipolar disorder, and depression. The Uniform Assessment System-New York (UAS-NY) evaluation of 4 months ago showed that the patient is cognitively intact; making decisions independently in a reasonable and safe manner; independent with phone use, bed mobility; requiring supervision for managing finances, stairs, bathing, personal hygiene, upper/lower body dressing, walking, locomotion, toilet use/transfer, eating, set up to manage medications, requiring extensive assistance with housework, transportation; and requiring maximal assistance for meal preparation, and shopping. She lives in a 3-bedroom apartment with her two supportive sons. 

The requested health service is medically necessary. 

The requested increase for Consumer Directed Personal Care Aide from 21 hours per week to 35 hours per week is medically necessary because even though the patient is cognitively intact, making decisions independently in a reasonable and safe manner, and independent with phone use and bed mobility, she requires supervision for managing finances, stairs, bathing, personal hygiene, upper/lower body dressing, walking, locomotion, toilet use/transfer, eating, set up to manage medications; requires extensive assistance with housework, transportation, and requires maximal assistance for meal preparation, and shopping. The reason for denial by the health plan as stated in the clinical information above does not align with the patient's disability features as stated in the most recent Uniform Assessment System (UAS). Therefore, the 35 hours per week requested should be approved. The requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with a submitted diagnosis of chest pain. She was hospitalized for 2 days. Her past medical history includes recurring syncope, heart murmur, obesity, and preeclampsia/eclampsia. She presented to the hospital and Emergency Department (ED) for evaluation following syncope. She was in a train when she felt heart palpitation, chest tightness, and dizziness and felt like she was going to pass out. She left the train and while walking upstairs passed out for about two minutes. There were no associated seizure findings. Vitals were stable. Blood pressure was 102/66. On examination, the patient appeared in no distress. Laboratory studies were unremarkable. Electrocardiogram (ECG) showed sinus bradycardia, rate 57. Treatment included intravenous fluids and she felt improved and left against medical advice. Inpatient hospital admission is under review.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, the documentation submitted for review does not establish the requested acute inpatient hospital stay was medically necessary for this patient. Criteria for inpatient hospital stay are not met, including suspicion of imminently dangerous cause, like pericardial tamponade, pulmonary embolism, syncope causing injury requiring hospitalization, inpatient admission required rather than observation care because of a significant finding or clinical condition judged too severe or too persistent to be within scope of observation care, such as hemodynamic instability that is severe or persistent, cardiac arrhythmias of immediate concern, acute coronary syndrome or myocardial infarction, structural cardiac disorder like severe aortic stenosis or suspected as cause that requires immediate correction, respiratory distress, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care, or other significant finding or clinical condition judged not to be within scope of observation care. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient stay. The care the patient received for uncomplicated recurrence of benign vasovagal syncope like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the requested health service is not medically necessary.