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

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

The patient is a gentleman that underwent total right hip replacement. His past medical history was significant for paroxysmal atrial fibrillation. Previous echocardiogram revealed a preserved LV (left ventricle) ejection fraction. He developed palpitations and worsening hip pain while in a rehabilitation facility. He called 911 and was taken to the hospital.  

Upon arrival, the patient's physical examination was unremarkable. His pulse was 75 bpm (beats per minute). An ECG (electrocardiogram) taken prior to arrival revealed narrow complex tachycardia at a rate of 165 bpm (beats per minute). The patient was admitted to telemetry for monitoring and was subsequently discharged. 

The patient's CK (creatine kinase) was elevated, but lower than previous values obtained following hip replacement surgery. CT (computerized tomography) angio of the chest demonstrated no evidence of pulmonary embolism. The patient was ultimately discharged on beta blocker and oral anticoagulant therapy.

No, the Inpatient admission was not medically necessary.

This patient presented with palpitations and had a known past history of paroxysmal atrial fibrillation. Upon arrival to the ED (emergency department), his heart rate was normal, and his arrhythmia had spontaneously terminated. He was effectively treated with AV (atrioventricular) nodal blocking agents. Pulmonary embolism was ruled out, and CPK (creatine phosphokinase) elevations were trending lower as compared to his post-operative lab tests.  

Bellew et al. (et alii) studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. AHA (American Heart Association) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission (Reference 2). This patient reverted to normal sinus rhythm spontaneously and was in normal rhythm upon arrival. In conclusion, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/orthodontic procedure. 
The insurer denied braces. 
The denial is overturned.

The patient is a female. She has a Class 1 malocclusion with severe crowding and protrusive incisors. She is treatment planned for orthodontics to correct the crowding and protrusion, which was denied by the health plan on the basis that treatment is not medically necessary. The subject under review is the medical necessity for the treatment. 

The health plan's determination is overturned.

The requested treatment of braces are medically necessary. Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.1 Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ millimeter (mm) overjets, which this patient has.2 For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Duplex scan, a special kind of picture of the heart and the blood vessels of the heart (93978).

The insurer denied the Duplex scan, a special kind of picture of the heart and the blood vessels of the heart (93978).  The denial is upheld. 

The patient is a female with a history of 4 mm (millimeter) non-ruptured brain aneurysm (status post coiling procedure), hypertension, dyslipidemia and TIA (transient ischemic attack).  She is a former smoker.  The patient had complaints of back pain.  CPT code 93978 - (Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study) was requested for screening for abdominal aortic aneurysm.  This study was denied by the plan.  CPT code 76706 (Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA)) was approved.

No, the Duplex scan, a special kind of picture of the heart and the blood vessels of the heart (93978) is not medically necessary.

The patient has a history of cerebral aneurysm, hypertension and tobacco use; thus, it would be reasonable to assess her abdominal aorta to screen for Abdominal Aortic Aneurysm.  The ultrasound study routinely used for is the CPT code 76706 (Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA)), which was approved but has not been performed thus far.  The medical necessity of a more extensive study: CPT code 93978 - (Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study), in the absence of the results from the screening study could not be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: S/P (status post) Unwitnessed fall
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a history of alcohol and cannabis abuse and deep venous thrombosis/pulmonary embolism on Coumadin.  He presented to the emergency department from a detoxification facility after an unwitnessed fall.  

The patient's labs were notable for white blood cell count 10,600, hemoglobin 11.5, bicarbonate 37, potassium 4.4, and creatinine 1.3.  Radiographs demonstrated no fracture.  The patient was afebrile with the policy and blood pressure and 98/68.  Computed tomography of the brain demonstrated no acute process.  The electrocardiogram showed sinus rhythm without acute ischemic changes and cardiac enzymes were negative.  Intravenous fluids were provided along with an alcohol thrall protocol and a methadone taper.  The stool hemoccult was positive; the patient declined a recommendation for computed tomography of the abdomen/pelvis.  The creatinine dropped to 1.0-1.1 and the hemoglobin was 12.1 on follow-up.  It was determined that the presentation was likely due to a vasovagal or orthostatic episode.

No, the Inpatient admission was not medically necessary.

The patient had a fall, which was felt to be due to a vasovagal or orthostatic episode, but he did not have syncope.  Radiographs demonstrated no fracture, and computed tomography of the brain demonstrated no acute process.  There was no evidence of seizure activity, arrhythmia, acute cerebrovascular accident, or acute coronary syndrome.  There were no decompensated medical comorbidities.  The hemoglobin remained stable and there was no evidence of active bleeding.  A blood transfusion was not required.  The patient remained hemodynamically stable.  There was no evidence of alcohol or drug withdrawal during the hospital stay.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient Hospital

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

The patient is a female with a past medical history (PMH) of hypertension and a SAH (subarachnoid hemorrhage). Apparently a first cerebral angiogram was negative for a clear source, but a repeat study during the same admission reported a very small aneurysm 0.7 mm just off the dorsal wall of the SCA (superior cerebellar artery) with mild regional vasospasm as well as a small 1mm left proximal A1 segment aneurysm. No treatment was undertaken for the small aneurysms at that time. The patient underwent a recommended follow-up cerebral angiogram to evaluate for any change in the previous findings and possible embolization as indicated. This reported that the SCA aneurysm and mild vasospasm was no longer visualized, and the small 1mm left A1 aneurysm was unchanged. The procedure was carried out under general anesthesia as a class American Society of Anesthesiologists (ASA) III patient. The angiogram was uncomplicated according to the procedure note and anesthesia records. The patient was required to lie flat for 6 hours and be monitored for any change in neurological status as well as for groin hemorrhage. She remained stable and was discharged in good condition.

The inpatient hospital admission was not medically necessary for this patient for an elective diagnostic cerebral angiogram that did not require intravascular intervention to treat the patient's remaining small intracerebral aneurysm.
The patient was undergoing an elective follow-up angiogram several months after her initial episode of subarachnoid hemorrhage that had not required procedural intervention during her earlier admission. The angiogram was uncomplicated and did not require aneurysmal embolization, and although carried out under general anesthesia with the usual requirements to activity restrictions and monitoring for a groin hematoma, could easily have been performed at a lower level of care. That would have been different had there been a need for direct treatment with embolization or bypass of one or both of the aneurysms. If that had occurred, the patient would have required post-procedure monitoring in an intensive-care setting for some time, and an inpatient status would have been necessary in that situation. Fortunately, that was not the case for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rectal cancer, abdominal pain.
Treatment:  Inpatient admission.

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

The patient is a female with history of (h/o) rectal cancer, for which she underwent low anterior resection, chemotherapy and radiation.  She presented with two months history of (h/o) abdominal pain and diarrhea to her primary care physician (PCP), which prompted an outpatient computed tomography (CT) of the abdomen.  The computed tomography (CT) revealed a mass in the tail of the pancreas measuring 6.8 centimeters by 4.0 centimeters (cm) with an encasement of the celiac and superior mesenteric artery (SMA) vessels.  The patient's labs revealed normal complete blood count (CBC).   Comprehensive metabolic panel (CMP) revealed mild hypokalemia with potassium (K) at 3.2. 

As an outpatient, the patient received a course of Cipro for seven days, and after four day of antibiotic course, she did not improve.  She was sent by her primary care physician (PCP) for endoscopic ultrasound.  On admission, the patient was hemodynamically stable and afebrile.  She underwent esophagogastroduodenoscopy (EGD), which revealed gastritis.  Endoscopic ultrasound was also done, and the fine needle aspiration of the pancreatic mass and liver lesion was done without any complications.  She was discharged home in a fair and stable condition after the procedures.

No, the proposed acute level inpatient care was not appropriate or medically necessary for the management of this patient's condition. 

The patient presented with two months history of (h/o) abdominal pain and diarrhea to her primary care physician (PCP) office and was empirically treated with Cipro, which did not improve her symptoms.  The computed tomography (CT) scan of the abdomen was done to further evaluate her symptoms and that revealed a pancreatic mass.  The patient was sent to the hospital for endoscopic ultrasound and biopsy of the mass.  The patient was mildly hypokalemic, which was corrected with potassium (K) supplements.  She remained hemodynamically stable and afebrile and tolerated diet without any exacerbation of abdominal pain and diarrhea.  She was discharged home after her endoscopic procedures with outpatient follow-up.  Given this clinical scenario, the acute level inpatient care was not medically necessary, and she could have safely managed under lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic brain injury

Treatment: Continued skilled nursing care

The insurer denied coverage for continued skilled nursing care.

The denial is upheld. 

This is a male patient who sustained a traumatic brain injury in the past with resultant left subdural hematoma and status post hemi-craniectomy. The patient also required tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. The patient underwent a cranioplasty and was transferred to a skilled nursing facility (SNF) for subacute rehabilitation. The patient was transferred back to the acute hospital for seizures and subsequently readmitted to the SNF.  Under review is the medical necessity for continue skilled nursing care on or after day 14 of re-admission.

The clinical records demonstrate a level of physical impairment that supported the medical necessity for trial subacute rehabilitation services at the SNF. However, on and after day 14 of re-admission, the treatment notes do not document any substantial improvement for the patient. For example, according to the physical therapy notes, the patient remained totally dependent for functional mobility (including bed mobility and transfer activities). A similar level of dependence and lack of improvement was documented by the occupational therapist. The patient remained at the total assistance level for activities of daily living. There were no specific acute medical problems or complicated nursing issues preventing the patient's safe discharge to a lower level care effective on or after day 14 of re-admission.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued skilled nursing care on or after day 14 of re-admission was not medically necessary.

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

The carrier's denial of coverage for continued skilled nursing care should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, Orthopnea, Pericardial effusion
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a female patient who had a history of focal segmental glomerulosclerosis with end stage renal disease treated with hemodialysis three times per week. The patient was started on nifedipine daily by her nephrologist for hypertension and was undergoing evaluation for renal transplantation. The patient presented to the Emergency Department (ED) with a 2 day history of dyspnea, dry cough, and orthopnea. The patient's initial vital signs included blood pressure (BP) 160/93, heart rate 105, temperature 98.2, respiratory rate 22, and oxygen saturation on room air 94%. The patient's chest X-ray revealed mild congestive heart failure and she was started on supplemental oxygen. The patient's electrocardiogram (EKG) was normal. The patient's computed tomography (CT) angiography of the chest on day 2 of admission to rule out pulmonary embolism was negative for pulmonary embolism but revealed a moderate to large pericardial effusion and findings consistent with moderate to severe pulmonary edema. The patient's echocardiography on day 2 of admission revealed a moderate-sized pericardial effusion with no evidence for diastolic right ventricular collapse or significant respiratory changes in transmitral flow velocity. The patient was treated with hemodialysis on 3 consecutive days, removing 2.5, 2.3, and 2.8 liters of fluid, with improvement in her symptoms and hypoxia. The patient's nifedipine dose was increased to improve blood pressure control and she was discharged on day 4 of admission with this increased dose plus her home dose of metoprolol.  

Based on the review of literature and the patient's medical record, the inpatient admission was not medically necessary for this patient. There is no evidence that this patient required an inpatient level of care for additional hemodialysis to treat this patient's fluid overload that caused her dyspnea from pulmonary vascular congestion, as well as her pericardial effusion. In addition, echocardiography did not reveal any evidence for tamponade physiology requiring inpatient monitoring and management. Diagnosis could have been completed at an observation level of care, followed by outpatient hemodialysis. There was no evidence that this patient was at increased risk for adverse cardiovascular events requiring inpatient monitoring and management, based on her clinical presentation and results of testing performed in the ED and then shortly after admission.

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 should be upheld. The medical necessity is not substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Treatment: Nurtec 75MG (milligram) 
The insurer denied the Nurtec 75MG (milligram).
The denial is upheld. 

The patient is a female with migraine headache disorder. She has tried and failed ketorolac, indomethacin, tramadol and Ubrelvy for abortive therapy. 

No, the treatment with Nurtec is not medically necessary.
 
There is no documented reason provided as to why the patient cannot be treated with the preferred abortive medications. All of the preferred triptans are FDA (Food and Drug Administration)-approved for migraine abortive therapy and are considered to be first-line, standard-of-care treatment (Cameron, et al). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Nurtec relative to triptans. Therefore, the treatment with Nurtec is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Inpatient hospital

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

The patient is a woman with a history of headaches, anxiety and recurrent herpes zoster who presented to the emergency department. She presented with a chief complaint of blisters on her wrist. She had multiple flares of herpes zoster over the past four years. She had been diagnosed with another zoster flare by her primary care physician and took Valtrex for two weeks without improvement. She reported pain that was seven out of 10 in severity. Review of systems was negative for fevers and chills. On physical exam, heart and lungs were unremarkable and she had pustular lesions on her wrist with linear streaks extending to the armpit. The patient was admitted for shingles and cellulitis of the right upper arm. 

The inpatient hospital admission was not medically necessary.
The patient did not have any significant complications related to zoster at the time of the hospital admission. She had failed outpatient antibiotics, but did not have a complex infection or abscess and therefore could have been managed safely and effectively at a lower level of care. Specifically, there was no evidence of sepsis, no evidence of uncontrolled pain, and no evidence of involvement of sensitive susceptible tissues such as zoster ophthalmicus.
The patient had failed outpatient antibiotics and required intravenous antibiotics, but this was an uncomplicated case of shingles and cellulitis. She was not hemodynamically unstable, did not have evidence of systemic infection or toxicity, and did not have other complicating medical history. The inpatient hospital admission was therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: S/p (status post) Surgery (total hip replacement)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She was admitted to hospital for elective right hip replacement. Her past medical history was significant for morbid obesity (BMI [body mass index] 41.2), hypertension and pre-Diabetes. 

The patient's operation was non-complicated. She was able to ambulate 35 feet with minimal assistance on POD (post-operative day) #1. She was cleared for discharge, which was completed two days after admission.

No, the inpatient admission was not medically necessary.

The medical record demonstrates a non-complicated post-surgical course. There was no evidence of problems with the wound. The patient was able to tolerate oral medications. Her vital signs and hematocrit were stable. She was able to ambulate with assistance POD (postoperative day) #1. She did not require treatment for an underlying medical condition. There was no evidence of "fever, bleeding, infection."

The progress records demonstrated "resting comfortably without complaints, pain tolerated." The physician progress record on day 1 notes need for, "discharge planning." There were no conditions evidenced in the medical records which substantiate acute level service. 

The above findings do not substantiate necessity of the inpatient level of service. MCG Guidelines for Goal Length of Stay have been met (i.e., [id est] ambulatory).

Therefore, given the above, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with chronic CHF (congestive heart failure) and severe left hip pain. 

The patient underwent an elective left total hip replacement earlier in the spring. He received neuraxial block with operative time of one hour and six minutes. His ASA (American Society of Anesthesiology) score was 3. 

The patient's post-surgical course was complicated by anemia. He was monitored for blood transfusion, which he did not receive. He had changes to his IV (intravenous) fluid and had required monitoring to hemodynamic status. He was evaluated and able to walk 100 feet independent. He was discharged home. 

The Inpatient admission was medically necessary.

The medical record demonstrates complications encountered after the operation. There was evidence of bleeding and abnormal vital signs. The patient was found to have his hematocrit at 23 on POD (postoperative day) #1. There was concern for necessity of transfusion if the condition did not stabilize. He received fluids with subsequent correction. He had underlying cardiac disease, and post-surgical anemia of such extent could cause a problem. He would be at risk for volume abnormalities as well as increased CHF (congestive heart failure). The patient's diastolic BP (blood pressure) was approximately 50 mmHg (millimeters of mercury) lower than his norm (i.e. [id est], 155 vs 97). He would be at high risk for possible syncope. These factors substantiate necessity of admission and length of stay as provided. The MCG (Miliman Care Guidelines) criteria had been met.