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

Primary Diagnosis: Digestive system/ Gastointestinal Abdominal Pain
Primary Treatment :Inpatient Hospital

Summary:
This patient  with a history of hypertension, diabetes, asthma and human immunodeficiency virus (HIV) who presented to the emergency department with abdominal pain. On presentation, the patient had a temperature of 98.5, pulse rate of 73, blood pressure of 100/62, respiratory rate 18, and an oxygen saturation of 97% on room air. The health plans determination  is upheld in whole .
On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork was notable for leukocytosis without anemia or significant electrolyte derangements. The patient's CT of the abdomen/pelvis revealed acute descending colon diverticulitis. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and antibiotic therapy. The patient remained hemodynamically stable and did not develop phlegmon/abscess, gastrointestinal bleeding, bowel obstruction or perforation and did not require surgical intervention. Based on nationally recognized guidelines, the patient did not have peritoneal signs, hemodynamic instability, persistent gross bleeding per rectum, significant abnormality on imaging study including abscess, fistula, obstruction, ileus or free perforation, immunocompromised patient, high fever, severe pain requiring inpatient management, severe electrolyte abnormalities, ongoing transfusion for blood loss, or require parenteral nutrition, percutaneous drainage or surgery and therefore an acute level of care and inpatient admission was not medically necessary. This is consistent with generally accepted standards of medical practice as supported by nationally recognized peer reviewed literature and guidelines.
Appeal type: Medical necessity
Decision: Upheld

Blood Disorder
Inpatient Hospital

At the time of this admission the pediatric patient had an elevated lead level of 38 mcg/dl, secondary to ingesting paint chips. An abdominal x ray showed paint chips in the gastrointestinal (GI) tract. Lab results included a hemoglobin (Hgb) of 8.9, a ferritin of 3.9, and an iron level of 17 mg/dl. A basic metabolic panel (BMP) showed a bicarb of 17 and a sodium (Na) of 135. The remainder of the labs were normal.
Of, note, the patient has a developmental delay, with a prenatal history significant for the patient's mother having an elevated lead level.
The patient was admitted to the floor for bowel cleaning and was given Golytely via an NG (nasogastric) tube; a repeat abdominal x ray showed some improvement. There was no documented evidence of any distress or metabolic perturbation other than the elevated lead level. The patient progressed well, as expected and was discharged in stable condition after 2 days of hospitalization.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. The patient had a lead level less than 45 mcg/dl. The level of chelation is 45 mcg/dl and above. In chelation treatment one must be inpatient because of the potential for electrolyte abnormalities and metabolic perturbations. As per the current practice guidelines and Centers for Disease Control and Prevention (CDC) recommendations, in patients with lead levels 20- 44 mcg/dl there is no need for chelation. In this admission, there was no change in the physical exam and the vital signs were stable. Patients would need only labs such as complete blood count (CBC), comprehensive metabolic panel (CMP), zinc protoporphyrin (ZPP), and abdominal imaging. In this patient, there was no distress nor any metabolic perturbations, and patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment Inpatient Stay.  The insurer denied the Inpatient Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with a new onset of severe chest pain which she described as precordial, radiating to the left axilla, sharp, 5/10 in intensity. The pain was provoked with movement of the hand and turning during sleep. The pain was keeping her up at night for a couple of nights. She also was complaining of bilateral leg swelling, which she had for 2 months; the lower extremity (LE) swelling was less in the morning and worse in the evening. She had a chronic mild cough with a small amount of white sputum.

The patient had a history of hypertension, hyperlipidemia and tobacco abuse. Her vital signs in ED were normal. Her physical examination was unremarkable. She had tenderness on the second intercostal region and precordium.

Left shoulder movement provoked pain in the chest. There was no restriction of movement in other joints. Her electrocardiogram (ECG) was normal. Her chest x-ray (CXR) revealed left retrocardiac subsegmental atelectasis. The patient was admitted to the hospital with a diagnosis of chest pain, rule out unstable angina versus acute costochondritis.

The patient was treated with nonsteroidal anti-inflammatory and pain medications. She also was treated for her hypertension. A cardiology consultation was obtained. She underwent an echocardiogram. Her echocardiogram was unremarkable.

The patient's condition was stable. Her serial cardiac enzymes were normal. Her thyroid stimulating hormone (TSH) was elevated to 7.67 and her low density lipoprotein (LDL) was 195. The patient was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. This patient presented with atypical chest pain, which had features compatible with musculoskeletal chest pain. Her work up was negative for cardiac causes of chest pain. Her troponin, ECG and echocardiogram did not reveal any abnormalities. The patient was observed and evaluated appropriately given her coronary risk factors (smoking and hypertension). However, her condition was stable and the care did not meet criteria for an inpatient level. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System/ Asthma
Inpatient Hospital

The patient is a young female with a past medical history of asthma who presented to the ED with a 1 day history of wet cough and runny nose associated with subjective fever. Her mother noticed belly breathing the night prior and she gave nebulized Albuterol x 1 and Motrin x 1 but on the day of presentation she noticed difficulty breathing so she decided to come to the ER. She also reported the child was not eating at baseline but was tolerating oral intake with 5-6 wet diapers. In the ER she presented with temp 100.9, heart rate (HR) 184, respiratory rate (RR) 39 and oxygen (O2) sat 100% on room air. Her RR went up to 55, the patient was noted on exam to have bilateral (B/L) expiratory wheezing, tachypnea and pan retractions. She was given Combi nebs x 3, Solu-Medrol, Magnesium Sulfate, normal saline (NS) bolus and albuterol neb Q2hr. After 3 Combi nebs she continued with wheezing and retractions. Her RR was 40/min. She had normal chest x-ray (CXR) in the ER. She was negative for both respiratory syncytial virus (RSV) and the Flu. After 4.5 hours in the ER she was reevaluated and continued to have tachypnea with wheezing and belly breathing. The decision was made at that point to admit to the floor.

She was admitted for reactive airway disease (RAD) for further management and to monitor respiratory status. She was started on Albuterol Q2hrs as well as systemic steroids. The morning after admission, the patient was assessed and found to have RR 40 and good air entry at 2hr post Albuterol treatment. She did have end expiratory wheezes at bases. The patient was gradually weaned to Albuterol q4 hrs, which she tolerated. Prior to discharge she was in no respiratory distress, afebrile, and tolerating oral feedings adequately. At issue is the medical necessity of the inpatient stay.

The health plan's determination is overturned. The literature recommends admission and close monitoring for patients with persistent respiratory distress in the face of an asthma exacerbation after proper ER management has been implemented. This patient was symptomatic enough to require IV magnesium as systemic steroids and bronchodilators were not sufficient to control her symptoms. These patients are more likely to experience deterioration and need for higher acuity of care once admitted. She still had wheezing and retractions at the time of admission and required nebulizer treatments every two hours. Such frequent treatments which would also require increased monitoring would not be appropriate for a lower level of care. Even though the length of her stay did not span 2 midnights, the intensity of services provided and the condition of the patient when the decision to admit was made necessitated inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystitis 
Treatment: Acute inpatient hospital stay 

The insurer denied coverage for acute inpatient hospital stay. The denial is upheld. 

This patient is a male with no past medical history. The patient presented to the Emergency Room (ER) with 2-day history of fever, hematuria, generalized body aches, sharp suprapubic pain, chills and dysuria. In the ER, the patient's triage vitals revealed blood pressure 92/58, temperature 98.80F; the patient's lab revealed white blood cell (WBC) 16,400, platelets 111,000, lactate 1.68; the patient's urinalysis revealed protein, blood, positive nitrites, and few bacteria. The patient's computed tomography (CT) scan revealed no urinary tract calculus or obstruction; mildly enlarged prostate; mild stranding in fat adjacent to urinary bladder consistent with cystitis. The patient was treated with intravenous (IV) fluid bolus, Toradol, and IV antibiotics. The patient was admitted with diagnosis of cystitis. With treatment, the patient's hematuria resolved. The patient's urine culture grew E. coli bacteria. The patient's blood cultures were negative for microbial growth. The patient's repeat urinalysis showed small blood and trace of leukocytes. The patient's medication was changed to oral antibiotics and was discharged home. 

Based on the review of the medical record, the patient did not meet the MCG clinical criteria for inpatient admission for urinary tract infection. The patient did not have hemodynamic instability, failure of out-patient treatment, urinary obstruction, immunocompromised state, recent urologic manipulation or procedure, abscess that required drainage. The patient's urinary tract infection could have been treated as outpatient. The patient was afebrile at the time of admission, and did not present with clinical signs and symptoms that were concerning for bacteremia. The patient's CT scan failed to show signs of urinary obstruction or calculus that would complicate this patient's urinary tract infection. The patient also had no medical history such as uncontrolled diabetes that put this patient at high risk for bacteremia and need for intravenous antibiotics and closer monitoring. This patient could have been discharged home on oral antibiotics and close follow-up with his primary care provider. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for acute inpatient hospital stay should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute pancreatitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Acute Inpatient Hospitalization was not medically necessary. The care as provided was medically appropriate, but the level at which the care was provided was not medically necessary.

This is a female patient who has a history of being bed-bound. The patient has cholelithiasis, chronic kidney disease, and recurrent pancreatitis. Her last prior admission was earlier that year. The patient presented with epigastric abdominal pain as well as a lipase exceeding 1800. 

The patient received intravenous (IV) morphine for pain and supportive care. The patient tolerated an oral diet. The patient had a re-admission within 30 days of two prior hospitalizations for the same condition. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level. Indeed, the patient was tolerating an oral intake during this stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe headache; possible cerebrovascular accident.

Treatment: inpatient hospital admission

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

This patient is a female with no significant past medical history.  The patient presented to the Emergency Department (ED) complaining of the worst headache of her life.  The patient also indicated that she was having memory loss and speech issues for the past month. The patient had complaints of vomiting and diarrhea, as well. In the ED, the patient's vital signs revealed a temperature of 98.2 degrees with respirations at 19.  The patient's blood pressure was 147/91 with a heart rate of 109.  The patient reported that she had 3 migraines in her life, and this headache felt different. On exam, the patient's speech was clear and understandable, and the patient was able to move all extremities with equal strength.  There was no facial droop noted, and the patient's pupils were equal and reactive to light.  The recommendation was made for medication administration as well as multiple laboratory and diagnostic studies.  The patient's bloodwork showed an elevated white blood cell count 12.26.  The patient's computed tomography (CT) scan of the head revealed no acute intracranial findings. 

 The patient upon reevaluation stated that she was having sudden onset of her right eye blindness. However, the patient's neurological exam remained intact.  Upon the third recheck, the patient's symptoms improved with her vision returning to the right eye.  It was recommended that the patient be admitted for further evaluation.  The patient was treated with pain medication as needed and underwent a magnetic resonance imaging (MRI) of the brain.  The MRI of the brain revealed no significant abnormalities.  The patient was reevaluated by Neurology at which the patient was noted to be clinically improved with medication. The patient was discharged with instructions to follow-up as outpatient.

Based on the review of the medical record, this patient was then a female who presented to the Emergency Department (ED) with severe headache with report of speech difficulty and memory loss, and transient loss of vision in the right eye. The patient's magnetic resonance imaging (MRI) of the brain coupled with the patient's computed tomography (CT) scan of the head were unremarkable for acute pathology, such as ischemic stroke. Based on the care that was provided to this patient, literature supports that this patient's inpatient care could have been provided safely and effectively at a less intensive level of care. Appropriate imaging studies, medication treatment, and neurology consultation could have been performed in the ED or on an observation basis as recommended. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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 hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation

Treatment: Inpatient admission 

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

This patient is a male with a history of atrial fibrillation, coronary artery disease, status post stent placement, cardiomyopathy, asthma and COPD. He presented to the Emergency department for complaints of palpitations, shortness of breath, coughing and weakness. Initial exams showed heart rate of 155 bpm, oxygen saturation of 92%, mild tachypnea, poor air entry, and wheezing. EKG showed at atrial fibrillation with rapid ventricular response rate at 167 bpm. Initial lab findings showed elevated BNP of 332. The patient was seen by a Cardiologist and was admitted to the telemetry unit for continued monitoring. Hospital course of treatment and management included strict I&O, continuous pulse oximetry, Atrovent nebulizer, Lopressor, Aspirin, oxygen 3 liters via nasal cannula, and daily weights. The patient still had an elevated heart rate of 125 bpm with irregular rhythm. The patient underwent Transesophageal Echocardiogram and Cardioversion. The patient was cleared for discharged.
The patient presented with atrial fibrillation. The remainder of the cardiac workup was unremarkable, including unremarkable cardiac troponin. The patient remained clinically and hemodynamically stable throughout the hospitalization. 
The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 
Inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Inpatient admission criteria were not met.  Although the patient had new onset symptoms, criteria were not met for any other additional extenuating circumstances. Observational care would have been appropriate. 

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

Diagnosis: shortness of breath; pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary.

The patient is a male with history of COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure) with shortness of breath. He was admitted for hypoglycemia and pneumonia. The patient received IV antibiotics. The patient was discharged home with oral antibiotics after one day in the hospital.

The patient was found to have pneumonia as well as hypoglycemia at the time of emergency room care. The patient was also tachycardic and tachypneic at the time of emergency evaluation. The patient was started on IV antibiotics, and hypoglycemia was reversed. The patient's CURB-65 (confusion, BUN, respiration rate, BP, Age 65+) score is zero and is a low risk group for adverse outcomes. 

At the time of admission, the patient was hemodynamically stable. The patient's physical exam was within normal limits (WNL). The blood work was within normal limits except hypoglycemia, which was corrected in the emergency room. The imaging revealed pneumonia. There is no clinical documentation of trial and failure of outpatient level of care. The patient has Curb-65 score of 0, which makes this patient appropriate for outpatient level of care. The patient was able to take oral medications. The acute in hospital level of care was not medically necessary.  The appropriate level of care from would be outpatient level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Missing teeth
Treatment:  D5214 Partial Lower Denture, D2791 All Metal Crown, Tooth 15 and D2791 All Metal Crown, Tooth 14
Decision: Partially Overturned

Summary:
The patient is a female requesting dental benefit for single crowns on teeth #'s 14 and 15, and a lower partial denture.

The patient is missing teeth on both sides of her lower jaw, so replacing them with a partial denture would help her chew. Therefore, the request for a lower partial denture, code D5214 is medically necessary.

The crowns on teeth #'s 14 and 15 are not needed according to the x-rays sent. First of all, tooth #14 is part of an existing bridge, so placing a single crown on it is impossible. There is no decay seen on the x-rays, so replacing the bridge (if that is what was meant) is not needed. Tooth #15 does not exhibit any decay or fracturing, so there is no need for a crown at this time based on the limited information provided. The crowns are therefore not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chest pain
Issue under review: Nuclear perfusion imaging
The Health Plan denied Nuclear perfusion imaging
The health plan's determination is overturned.

The patient is an adult gentleman with a history of hypertension, hyperlipidemia, positive family history of CAD (coronary artery disease) and previous smoking.  Baseline ECG (electrocardiogram) revealed normal sinus rhythm with no ST or T wave changes.  He presented to his physician complaining of chest pain at rest. Echocardiography revealed a normal LVEF (left ventricle ejection fraction) and no valvular abnormalities.  Exercise perfusion testing was ordered and revealed no abnormality.

This patient has an intermediate pretest probability of coronary artery disease (Reference 1).  Patients complaining of chest pain and intermediate probability of coronary disease have a class I indication for exercise ECG with myocardial perfusion imaging. Both American and European societies of cardiology have listed perfusion imaging as a class I indication for patients with intermediate risk of coronary disease (Reference 2, 3).  In conclusion, the standard of care is to perform exercise myocardial perfusion imaging in this patient.