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

Diagnosis: Syncope	
Treatment: Hospital admission
The insurer denied coverage for the hospital admission.
The denial is overturned.

This a case of an adult patient that presented to the hospital with syncope. He reported nausea, vomiting and diarrhea for a three-day period prior to presentation. On arrival to the hospital, he was tachycardic with a pulse of 141 beats per minute  His blood pressure was 131/92. Physical examination was positive for generalized tenderness of the abdomen. 12 lead electrocardiogram (ECG) demonstrated sinus tachycardia with frequent ventricular premature complexes without ischemic ST or T wave changes.  Serum blood testing revealed an elevated high sensitivity troponin level of 108 nanograms per liter (ng/L), and an elevated Blood urea nitrogen / Creatinine (BUN/CR) ratio (32/0.98 milligrams per deciliter (mg/dl)). White blood cell count was elevated at 18.7. The patient was admitted to the hospital for work up and treatment.  He was diagnosed with gastroenteritis and a type II myocardial infarction. Echocardiogram demonstrated normal left ventricular (LV) function with an left ventricular ejection fraction (LVEF) of 60% and no significant valvular abnormalities. Following supportive treatment including intravenous fluids and antibiotics his condition improved and he was discharged home. 

This patient presented to the hospital with syncope, sinus tachycardia at a rate of 140 beats per minute, abdominal pain. Positive up trending serial serum troponin levels were concerning findings noted in his diagnostic work up that pointed to a cardiac etiology for syncope. In addition, he appeared to be volume depleted and required acute treatment. Although patients presenting to the hospital with syncope can often be risk stratified and rapidly discharged from the emergency department (ED), those with cardiac syncope are at high risk of future events that result in increased morbidity and even mortality.  (Reference 1,2) Admission to the hospital for work up with subsequent close follow up by a cardiac electrophysiologist was medically necessary.

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

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is an adult with past medical history of hypertension, sarcoidosis, nephrolithiasis, and cervical spine fusion. The patient presented to the emergency department with a complaint of abdominal pain. The patient was given intravenous fluids and pain medications. Computed tomography revealed a right distal vertical stone with right hydronephrosis. The patient underwent cystoscopy with semi-rigid ureteroscopy, stone basketing, and stent placement. The patient tolerated the procedure well with no complications and was discharged home after a period of medical stability. 

Per Milliman Care Guidelines (MCG) Health 25th Edition, Renal colic and kidney stones; patient fails to meet indications for admission to inpatient care and Urologic surgery or procedure GRG (general recovery care): patient is noted to have met the GRG discharge parameter within 24 hours post procedure.

As per these guidelines, this procedure is performed in the ambulatory surgery setting. The patient had no hemodynamic instability, renal failure, bilateral obstruction, or urinary tract infection evident.

Based on the above, the insurer's denial must be upheld.   The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult female with medical diagnosis of acute abdominal pain and presented to the Emergency Department (ED) with complaints of (c/o) abdominal pain and fever. Initial evaluation showed Temperature of 100.5 degrees Fahrenheit, examination revealed diffuse abdominal tenderness otherwise unremarkable with normal bowel sounds, no rebound. Ultrasound (US) done showed small intraluminal stones, negative Murphy's sign, common bile duct of 3mm (millimeters). There was no pericholecystic fluid and no gallbladder wall thickening. Labs showed minimally elevated alkaline phosphate of 133 with upper limit of normal of 126. The bilirubin was 0.3, white blood cells (WBC) 6.3, alanine transaminase (ALT) and aspartate transaminase (AST) were mildly elevated. The treating provider ordered inpatient admission.

There was no evidence of acute cholecystitis or other acute abdominal process needing acute inpatient management. 

"Gallstones or cholelithiasis are stones that form in the gallbladder composed of cholesterol, bilirubin, and bile. These stones are asymptomatic in most cases, with stones discovered incidentally. Symptomatic patients present with right upper abdominal pain after eating greasy or spicy food, nausea, vomiting, pain in epigastrium that radiates to the right scapula or mid-back." (Jones, et al., 2022).

"Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted." (Portincasa, et al., 2019).                                                  

Based on the above, the insurer's denial must be upheld. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Heart Rhythms
Treatment: Mobile cardiac outpatient telemetry
The insurer denied coverage for mobile cardiac outpatient telemetry
The denial is upheld

This adult presented to his physician complaining of recurrent palpitations. Symptoms were intermittent in nature. Prior evaluation, at an urgent care facility, failed to capture ECG (electrocardiogram) tracings while the patient was symptomatic.  His physician ordered a two-week mobile telemetry recorder to correlate symptoms with heart rhythm. Results revealed frequent premature atrial beats and runs of supraventricular tachycardia as well as occasional premature ventricular beats and non-sustained ventricular tachycardia lasting up to 12 beats in duration with a maximum rate of 203 bpm (beats per minute). The patient presented to his physician complaining of recurrent palpitations without syncope or near syncope. A mobile cardiac outpatient live telemetry monitor was placed and revealed non sustained arrhythmia.  It was medically necessary to utilize an external ECG monitor in this case (Reference 1,2). However, it was not medically necessary to have mobile telemetry.  Studies have demonstrated that mobile telemetry monitors are important in cases where patients are at risk for developing high degree atrioventricular (AV) block such as following transcatheter aortic valve replacement (TAVR) procedures (Reference 3). Current guidelines do not recommend Mobile telemetry over standard external multiday holter monitoring (Reference 2). In conclusion, continuous mobile telemetry monitoring was not medically necessary in this case. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for mobile cardiac outpatient telemetry services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intracranial Epidural Abscess.
Treatment: continued hospital admission.

The insurer denied coverage for continued hospital admission.  The denial is overturned.

This toddler presented to the hospital as a transfer from another facility with complaints of left eye swelling. He had facial and orbital cellulitis. Based upon imaging there was also concern for an epidural abscess. He underwent a bilateral nasal endoscopy with maxillary antrostomy with tissue removal via functional endoscopic sinus surgery (FESS), and was treated with intravenous vancomycin, ceftriaxone, and Flagyl. A Peripherally Inserted Central Catheter (PICC) line was inserted. 

The culture yielded heavy growth of Streptococcus anginosus, an aggressive pathogen that is known to cause intracranial abscesses as a complication of sinusitis. Vancomycin was discontinued as this organism is usually susceptible to ceftriaxone, however, continuous close observation was necessary, and he was followed by the Infectious Disease service.  Magnetic resonance imaging (MRI) of brain demonstrated slightly decreased size of left frontal epidural abscess and small stable epidural abscess laterally, with no evidence of sinus thrombosis, and no new intracranial collection. This was clinically reassuring and enabled the patient to be discharged home safely.

Continued stay in the hospital was medically necessary, as it would not have been safe to discharge the patient home without documenting a decrease in the size of his multiple intracranial abscesses after the vancomycin had been discontinued. This reassessment was also necessary to: 1) Decide on the need for repeat neurosurgical drainage procedure by neurosurgery if necessary, and 2) to plan the duration of intravenous therapy via PICC line at home

The plan of management, appropriately executed by the inpatient pediatric team, is consistent with the recommendations for treatment of intracranial epidural abscess in the review article referenced below. 

Based on the above, the insurer's denial must be overturned. 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 the continued hospital admission services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematemesis.
Treatment: Inpatient Stay.
The insurer denied: Inpatient Stay.
The denial is: Upheld.

The patient is a male with a past medical history significant for alcohol abuse who presented to the hospital with complaints of hematemesis for 2 days. The patient stated that he was drinking alcohol every day for the last several days. The patient shared that he drank significant amounts of alcohol in order to stop his shaking which prevented him from sleeping.
The patient denied fever, chills, abdominal pain, changes in bowel movements, or urinary habits. The patient denied chest pain, shortness of breath, or palpitations.
On the physical exam, the patient was afebrile. Heart rate was 87 beats per minute (bpm), blood pressure 147/78, respiratory rate 20 breaths/min, oxygen saturation 98% on room air.
He appeared to be a well-groomed individual who was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
A chest x-ray showed no evidence of an acute cardiopulmonary process.
The patient was admitted to the telemetry unit because of hematemesis. The admitting physician stated that the patient's hemoglobin was stable. The patient received treatment with proton pump inhibitors and was ordered serial hemoglobin and hematocrit (H&H) checks. The patient was diagnosed with rhinovirus for which he received supportive care.
Computed tomography (CT) scan of the abdomen and pelvis was performed and demonstrated no evidence of acute bleeding. The patient was seen by a gastrointestinal (GI) specialist who did not recommend esophagogastroduodenoscopy (EGD). The mildly elevated CPK levels consistent with mild rhabdomyolysis came down with hydration.
Since the patient remained in stable clinical condition, he was discharged.

The inpatient stay was not medically necessary for this patient.
Based on the patient's presentation and during the hospitalization, there was no clinical evidence of ongoing active gastrointestinal bleeding. The patient remained hemodynamically stable. This patient was not anemic.
After evaluation by a gastroenterologist, the patient did not need endoscopic studies. There was no evidence that the patient had a critically low platelet count or coagulopathy that would increase the chances of severe bleeding.
In addition, there was no evidence that the patient had severe pain that would justify admission at the acute inpatient level of care.
There was no mention that the patient developed significant alcohol withdrawal symptoms.
The rhabdomyolysis was mild and resolved very quickly after the administration of intravenous fluids.
Taking into consideration all these facts, the patient could have been managed at a lower level of care status given the clinical circumstances.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee pain

Treatment: Left knee replacement

The insurer denied coverage for inpatient admission

The denial is overturned 

This is a patient with a history of anemia and arthritis. The patient presented with left knee pain, and limited range of motion (ROM). The patient had a planned left knee replacement. At the end of the surgery the patient had a drain inserted for removal of multiple osteophytes and was kept for monitoring, pain control and consultation with physical therapy (PT). The patient was discharged home with physical therapy services.

The medical records denote significant underlying comorbidities which likely could result in complication. The presence of a Body Mass Index (BMI) of 56.7 (morbid obesity) is associated with an increased risk of problems. These include wound issues and exacerbation of underlying medical problems. 

The presence of the hemovac post-surgery with blood loss of 250 cubic centimeters (cc) followed by 60 cc is excessive. It would be important to monitor the progress for any evidence of continued bleeding. The records show ongoing pain medication requirements of intravenous (IV) narcotics. The procedure can be painful with the necessity of parenteral analgesia. Finally, the patient has a knee replacement on her right side. She would be very unlikely to be mobilized without assistance. Based upon her underlying medical conditions and the post-surgical record, inpatient admission and length of stay was necessary.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation / community acquired pneumonia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an elderly patient with a past medical history of asthma, atrial fibrillation, diabetes, hyperlipidemia, and hypertension. The patient presented to the emergency department (ED) with a 5 day history of chills, congestion, shortness of breath (SOB), wheezing and productive cough. The patient was ambulatory upon arrival to the ED.  Initial vital signs were Temperature 97.5 degrees Fahrenheit, Heart Rate 63, Respiratory Rate 20, Blood Pressure (BP) 131/62 and oxygen saturation 100% on room air. The patient was in no acute distress. Lung exam revealed coarse breath sounds and bilateral wheezes. Heart sounds were normal. The patient was alert and oriented x 3 with a non-focal neurologic exam.

White Blood Cell count (WBC) was 5,200. Hemoglobin 14.3, Other labs were within normal limits. Chest x-ray showed faint opacities of the right lower lobe, possibly pneumonia. The patient was admitted with diagnoses of asthma exacerbation/ community acquired pneumonia.

This patient was treated with intravenous (IV) steroids, bronchodilators, and placed on antibiotics - Rocephin and Azithromycin. The patient remained stable after admission, was afebrile, not hypoxic and hemodynamically stable. The patient was ambulatory and tolerating food and fluids. The patient was discharged home on oral antibiotics, steroids and other maintenance meds.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hrs. Patient was afebrile, stable and tolerating food and fluids. Oxygen saturations remained 98-100 % on room air. The patient had mild pneumonia, if present, with low pneumonia severity index (PSI) and CURB 65 (confusion, uremia, respiratory rate, BP, age >= 65 years) score of 1. His asthma was also mild and responded well to ED treatment. Patient could have been placed in observation initially and switched to oral antibiotics and oral steroids and bronchodilators after a period under observation, as he was quite stable overall. The patient could have been discharged home after a period in observation (which could be up to 48 hours) on oral medications with close follow-up in the outpatient setting.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease, CAD (coronary artery disease), CHF (congestive heart failure), and NIDDM (non-insulin dependent diabetes mellitus) with prior history of percutaneous cholecystostomy tube for calculous cholecystitis. 
Treatment: Inpatient Admission. 

The insurer denied: Inpatient Admission. 
The denial is upheld. 

The patient is an adult female with extensive medical co-morbidities including end stage renal disease, CAD (coronary artery disease), CHF (congestive heart failure), and NIDDM (non-insulin dependent diabetes mellitus) with prior history of percutaneous cholecystostomy tube for calculous cholecystitis. The patient was seen in the ED (emergency department) with waxing and waning mental status, abdominal pain, and low-grade fevers. The patient was afebrile during her admission. Her WBC (white blood count) was normal. Her cholecystostomy tube was unkinked. Positive UTI (urinary tract infection) was treated with antibiotics. She was subsequently discharged back to her nursing home. 

The Inpatient Admission was not medically necessary. 

The patient did not meet medical necessity for inpatient admission given that there was no major intra-abdominal pathology noted on CT (computed tomography) scan except for stercoral colitis due to constipation that was fixed with enemas. The cholecystostomy tube was in placed and unkinked in the ED (emergency department) without further complications. She did not have any signs of sepsis on laboratory data with a normal WBC (white blood count), and she did not demonstrate any signs of sepsis after her admission. She has known CHF (congestive heart failure) and renal dysfunction. Her UTI (urinary tract infection) was treated with antibiotics. Infectious disease saw her and recommended no further antibiotics, as she did not demonstrate any evidence of infection.  Therefore, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain/Vomiting
Treatment: Inpatient Emergency Admission
The insurer denied: Inpatient Emergency Admission
The denial is: Upheld

The patient is a female with medical history of asthma, iron-deficiency anemia, cannabinoid use, and cholecystectomy. She presented to the emergency department with right upper quadrant abdominal pain, nausea, and vomiting. She had ongoing vomiting.

Vital signs were notable for elevated diastolic blood pressure of 99 millimeters of mercury (mmHg). Physical examination was notable for soft, nondistended abdomen with right upper quadrant tenderness. Labs showed low hemoglobin of 7.4 grams per deciliter (g/dL) and hematocrit of 28.0% and unremarkable comprehensive metabolic panel. Computed tomography scan of the abdomen and pelvis showed mild thickening of the gastric antrum, which may represent gastritis, and lack of obstruction. She was treated with intravenous fluids, ondansetron, metoclopramide, morphine, famotidine, Toradol, Reglan, promethazine, and oral Carafate and lidocaine/nystatin/Benadryl/aluminum hydroxide.

After two days of treatment, she felt good, denied nausea, vomiting, and abdominal pain; she was tolerating a regular diet. Labs showed unremarkable basic metabolic panel. She was discharged on omeprazole and iron, with a plan for Primary Care and Gastroenterology follow-up. At issue is the medical necessity for the inpatient emergency admission.

The health plan's determination is upheld.

The inpatient emergency admission was not medically necessary for this patient.
Although the patient presented with nausea vomiting, and abdominal pain, she did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion. The presenting gastrointestinal symptoms of nausea and vomiting were assessed to be cannabinoid hyperemesis syndrome or gastroenteritis [1-6]. Additionally, the patient had iron-deficiency anemia. However, the patient did not have evidence of bowel obstruction, peritonitis, abscess, fistula, sepsis, ongoing gastrointestinal bleeding, or other complications warranting inpatient level of care [7,8]. No endoscopic procedures were deemed necessary during the stay. She had gradual improvement in symptoms with conservative therapy, consistent with the standard of care [3-8]. All of the measures that were undertaken, including monitoring, labs, and antiemetic therapy, could have been performed without the inpatient level of care.
Per the Milliman Care Guidelines for Abdominal Pain, Undiagnosed, the inpatient level of care is not supported.