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

Inpatient Hospital stay

The patient had an unwitnessed event. Spouse heard a loud noise and immediately went to where patient was working, the patient was unresponsive with shaking for 2-3 minutes. Patient was brought to the emergency room. By the time the ambulance got there the patient was able to ambulate to the ambulance, but was quite agitated and disoriented. A history of present illness could not be obtained from the patient because of  confusion, and the patient was not following simple commands, including opening eyes to voice. Sensorium gradually cleared. A computed tomography (CT) of the brain was negative. The patient had no abnormal findings on CT no localizing findings on neurologic exam. By report the patient had an episode of syncope recently with a negative workup. There is no mention as to whether this was associated with abnormal movements or altered mental status, as in this episode. The patient uses marijuana regularly and tetrahydrocannabinol (THC) urine drug screen was positive. After 2 days of hospitalization the patient was discharged for continued outpatient workup including electroencephalogram (EEG). Orders were given not to drive in the meantime. The health plan determination of medical necessity is overturned in whole. This patient did not have uncomplicated syncope. The patient had loss of consciousness, abnormal movements, a head injury from the fall, altered mental status which persisted after the return of consciousness, and a history of substance abuse. The differential diagnosis here is wide, including syncope with concussive encephalopathy related to the injury at the time of the syncope, primary seizure disorder, chemical intoxication from substances not on the urine drug screen-not uncommon in patients using illicit marijuana use, posterior circulation cerebrovascular insufficiency in a patient with risk factors, neurologic degenerative disease, and primary and metastatic malignancy not visualized on emergency room CT scanning.
Given the fact that this was the second episode of unexplained loss of consciousness, head injury in the altered mental status, inpatient admission for workup and assurance of stability rather than progression was absolutely medically necessary. Any other approach would have been dangerous for the patient.
Appeal type: Medical necessity
Decision: Upheld

CAD
Inpatient hospital stay

The patient has a history of coronary artery disease (CAD), previous 4 vessel coronary artery bypass graft (CABG) and previous stents, hypertension (HTN), hyperlipidemia (HLD), and type II diabetes. The patient complained of dyspnea on exertion and underwent a stress nuclear test. The test showed reversible perfusion defects in the inferior, septal and inferolateral areas consistent with myocardial ischemia. Cardiac catheterization was recommended.
Patient was admitted to the hospital and underwent cardiac catheterization which showed an occluded left internal mammary artery (LIMA) graft to the left anterior descending (LAD), and patent saphenous vein graft (SVG) to left circumflex (LCX). He was found to have an 80% posterolateral branch (R PL) stenosis. A drug-eluting stent was placed to this vessel. The procedure was uncomplicated. The patient was discharged on aspirin, Plavix, atorvastatin , gemfibrozil, and metoprolol, among other medications. The health plan determination of medical necessity is upheld in whole. The patient was electively admitted for coronary angiography and percutaneous coronary intervention. The procedure was uncomplicated. A lower level of care status is appropriate, but not full inpatient hospitalization. Per Milliman guidelines, coronary angioplasty is considered an ambulatory procedure. An extended length of stay may be needed for patients with unstable angina or acute myocardial infarction who undergo angioplasty or patients who have vascular or extravascular procedure-related complications. Other indications for admission would include need for inpatient CABG or need for intravenous glycoprotein IIb/IIIa inhibitors. The patient does not have any of these conditions, and could be treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure
Issue under review: Wearable cardiac defibrillator

Determination:
The Wearable cardiac defibrillator was not medically necessary.

The patient is an adult male that presented with non-ischemic systolic CHF (congestive heart failure) and severe aortic stenosis.  LVEF (left ventricle ejection fraction) was noted to be 16% on echocardiography.  

The patient underwent bio prosthetic aortic valve replacement.  Following surgery, the patient was discharged with an external Lifevest defibrillator.

An external life vest defibrillator is not medically necessary. The SCD HFT trial demonstrated a survival benefit in patients with NYHA functional class II symptoms of CHF and an LVEF less than or equal to 35% (1). Current guidelines do not recommend primary prevention of sudden cardiac death prior to treatment with anticongestive therapies for a several month period.  

This patient presented with a severely depressed ejection fraction and acute congestive heart failure in the setting of severe aortic stenosis.  His clinical presentation and hospitalization did not suggest high risk features for sustained ventricular arrhythmia or syncope. Although external Lifevest defibrillators have some evidence of being efficacious in treating patients with sustained ventricular arrhythmia, a recent study that enrolled high risk patients presenting with myocardial infarction failed to demonstrate a significant reduction in sudden cardiac death (3).  Based on current available guidelines and clinical trial data, the proposed treatment was not likely to be beneficial for the patient (4).
Appeal type: Medical necessity
Decision: Overturned

This is a patient  with a history of right proximal fibular mass, status/post (s/p) excision of the mass . The patient developed a soft tissue malignant neoplasm of the back consistent with dermatofibrosarcoma protuberans.
He underwent radial resection of the right low back mass with multiple soft tissue biopsies. A wound vacuum-assisted closure (VAC) was applied, and he was started on Lovenox and Ancef. He was admitted to the surgical unit after the surgery. The wound vac total area was 140 cubic centimeters (cc).
The preoperative plan was to do a closure procedure after the biopsy results from the margins were back.
The wound vac put out 200 cc.
The next day the VAC put out 350 cc. Lovenox was held. A lung nodule was noted on chest computed tomography (CT), and thoracic surgery consult was requested. Intravenous (IV) ancef was continued.
The patient underwent staged surgery with rotational muscle flaps of the paraspinal muscles, complex wound closure 32 centimeters (cm) in length, split thickness skin graft of 66 square cm, and application of a 66 cm square wound VAC.
The patient was continued on Eliquis and wound VAC. Ancef was continued. It was noted that he needed to remain in the hospital until the VAC drainage decreased appropriately.
He continued to improve. He was continued on IV ancef while the VAC was in place. The VAC output remained significant.
When the VAC output decreased to 10 cc, it was removed. The patient was discharged home, and IV Ancef was stopped. The health plan's determination is overturned. This is a patient who underwent a major tumor resection surgery, with radial resection of a back mass and need for 140 cm square wound VAC. The VAC was necessary to remove any excess drainage and minimize the likelihood of complications. It was appropriate to continue the intravenous Ancef while the VAC was in place.
The patient improved over the next two days, and a biopsy revealed clean margins of resection. The patient underwent wound closure surgery. In this particular case, this was also a major surgery, with multiple muscle rotational flaps needed and a complex wound closure of 32 cm and a VAC dressing. This type of complex wound closure can lead to significant drainage; if this drainage is not addressed appropriately such as with VAC therapy, then there is a significant risk of complications including infection and wound dehiscence. It is appropriate to continue IV ancef while the VAC is in place.
The wound drainage steadily decreased appropriately to the level where the VAC could be removed. IV antibiotics were stopped, and the patient was stable for discharge home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, vomiting
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with type 1 diabetes, hypothyroidism, and depression. She presented with severe shooting right upper quadrant abdominal pain and vomiting. 

On exam, the patient was afebrile with heart rate of 128 and blood pressure of 142/83. Ultrasound showed two cm (centimeter) mass behind the right ovary. CT showed 0.6 cm nodule adjacent to appendix, which was slightly increased from 2017 and hepatic steatosis. Glucose was 505 mg/dL, AST (aspartate aminotransferase) 133, ALT (alanine aminotransferase) 265, CO2 (carbon dioxide) 16, anion gap 25, beta hydroxybutyrate 3.1, and pH 7.3. 

The patient was treated with intravenous fluids, Tylenol, morphine, and Zofran. She was started on subcutaneous Lantus and Humalog. 

This patient had mild diabetic ketoacidosis. Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness (such as sepsis) [1]. This patient did not have alteration in her mental status, and she responded quickly to intravenous hydration and subcutaneous insulin therapy. She was not critically ill. She did not have sepsis. She had abdominal pain with modestly elevated transaminase levels. Her imaging did not reveal any acute processes that required inpatient intervention. Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.   

This is a female patient with a history of hypertension, type 2 diabetes mellitus, and morbid obesity.  She presented to the emergency room with complaints of chest pressure, dyspnea, right flank pain, nausea and vomiting. Her presenting vital signs were stable.  A computed tomography (CT) of the abdomen was performed, which was negative for renal calculi or obstruction.  Cardiology consulted on the patient.  Laboratory work-up was performed including Cardiac biomarkers with negative results. An echocardiogram was done which revealed a normal left ventricular size and systolic function with an ejection fraction of 55-60%.  There was moderate concentric left ventricular hypertrophy, trace mitral regurgitation and trace tricuspid regurgitation was present.  A nuclear stress test was performed with normal results.  She tested positive for influenza B; Tamiflu was administered.  She was deemed medically stable and discharged home.

The patient presented with chest pain.  The initial evaluation in the emergency room was unremarkable, including nondiagnostic electrocardiogram (EKG) and cardiac biomarkers.  Inpatient admission was not medically necessary for this patient.  The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing.  Further evaluation was warranted; however, inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

The health plan acted reasonably with sound medical judgment 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 is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis 
 
Treatment: Inpatient Admission 

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

This is a female patient with a history of hyperthyroidism and thyroidectomy, psychiatric disorder, polysubstance abuse and a stroke. She presented to the Emergency Department (ED) with complaints of abdominal pain, vomiting, and diarrhea. There was no abdominal rebound or guarding. Laboratory work up was performed revealing a white blood count (WBC) of 17.2. A computed tomography (CT) of the abdomen was performed with negative results for acute disease. Intravenous (IV) fluids and anti-emetics were administered. She was able to tolerate a liquid diet. She was medically stabilized and was discharged home. 

Clinical indications for admission for gastroenteritis (M-170) include a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, severe vomiting, severe dehydration, and an inability to maintain oral hydration. The patient did not have these conditions. This patient had gastroenteritis.  She could have received IV hydration and anti-emetics within observation status. Her renal function was normal. She did not meet MCG criteria for an inpatient admission for gastroenteritis. 

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

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: Fall
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a female patient over 30 weeks gestation who presented to the Emergency Department (ED) with complaints of a fall on her buttocks; she reported elbow and abdominal pain. Her vital signs on arrival were temperature 98.3F, heart rate 93, respiratory rate 20, and blood pressure 136/91. She had a positive toxicology screen for tetrahydrocannabinol. Upon evaluation it was determined that her elevated blood pressure was as a result of her noncompliance with medication. She was admitted due to suspected superimposed preeclampsia. She was treated with antihypertensive medications, magnesium for seizure prophylaxis, and Magnesium and betamethasone were given until preeclampsia was ruled out. She was consulted by Psychiatry. The biophysical profile was 8/8 and non-stress tests were reactive.  The patient was medically stable and discharged with instruction to follow up at diabetic clinic.

The patient presented after a fall.  However, the fall was on her buttocks, not on her abdomen.

In pregnancies that have reached the stage of fetal viability, continuous rather than intermittent fetal and uterine monitoring is recommended for at least four hours after even mild abdominal trauma to look for signs of preterm labor and abruption.  Monitoring is discontinued after a minimum of four hours in women with uterine contractions less frequent than 1 in 10 minutes, absence of vaginal bleeding, absence of abdominal pain, and a normal fetal heart rate tracing.
Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman.  So based on this patient's presentation, she did not have preeclampsia, but uncontrolled hypertension.

According to MCG: Indications for admission include:

1)	Severe preeclampsia or eclampsia 
2)	Onset of seizures
3)	Fetal compromise 
4)	Hemodynamic instability
5)	Hypertension and acute end organ damage.

This patient did not have any of the above.

This patient presented with blood pressure elevation due to non-compliance with medications.  Laboratory evaluation was normal and there was no evidence of preeclampsia. 

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deciduous tooth
Treatment: Dental services related to congenital anomaly

The Dental services related to congenital anomaly are medically necessary.

The patient is a female with an over retained upper right deciduous cuspid and absence of the permanent cuspid. The provider plans to remove the deciduous tooth, which is non-restorable, bone graft the area to provide adequate room for an implant in the #6 area.

The options in this case to restore function are an implant or a bridge. An implant is the best option. A bridge is considered radical treatment, as adjacent tooth structure must be drastically reduced in this process. The bridge has been regarded as the standard of care for some time in the replacement of single and multiple missing teeth. However, to obtain optimal functional and aesthetic results for full-veneer bridges, a significant reduction in the amount of tooth structure is necessary occasionally predisposing to endodontic, periodontal, and structural complications. The abutment teeth often become carious and have an increased rate of needing a root canal procedure. If one of the abutment teeth are lost, a longer span bridge would be required. 

The implant procedure is more conservative and has a better prognosis. Implants have a high rate of success, do not require procedures on adjacent teeth, and are not susceptible to caries. The bone replacement graft is needed to prevent resorption of bone prior to implant placement. It is well-documented that only partial bone fill of the alveolar socket occurs after an extraction. 

Studies show that three to four millimeters (mm) of both buccal - lingual and apicocoronal ridge resorption occurs within six months of extraction. Ridge preservation is a standard procedure that has been proven to preserve the alveolar bone and meets the standard definition of medically necessary. The decision to use sedation/general anesthesia for a particular dental procedure should only be determined by considering the needs of the patient, the requirements of the operating dentist and the effect on the quality of the dental treatment. The provider has determined that it is needed in this particular case.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

The patient is a male with Crohn's disease with history of recurring small bowel obstructions who presented to the hospital with epigastric pain rated 8/10, as well as nausea and vomiting. He was diagnosed with a Crohn's disease flare and admitted for gastrointestinal (GI) consultation and intravenous (IV) hydration. Computed tomography (CT) scan demonstrated interval resolution of the previously seen small bowel obstruction and some mild rectal thickening. He was then monitored in the hospital to ensure he could tolerate oral intake and then discharged home.

The health plan's determination is upheld.

The requested inpatient stay for this patient is not medically necessary.
The patient did not receive high acuity services after the decision to hospitalize the patient was made. There is no evidence the patient received any additional complex studies or therapy during the hospital stay. The patient did not receive monitoring or complex studies or treatment that could not have been provided at a lower level of care status. There is no documentation that the team found any special circumstances or problems specific to the patient that would have made treatment at a lower level of care inadequate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 

This is a patient who presented with a Class II malocclusion and significant spacing. She has an anterior open bite, and a significant (6 millimeter (mm)) overjet. She is treatment planned for 24-36 months of orthodontics with headgear to address the overjet and open bite, but the treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces. 

The health plan's determination is overturned. 

Patients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with an anterior open bite. (3) This patient is treatment planned for headgear to retract the upper teeth, which is less invasive than orthognathic surgery. 

Orthodontic treatment is medically necessary for this patient due to both the anterior open bite and the excessive overjet and protrusion of the maxillary incisors. As described in the response to question 1, orthodontics will improve the maximum bite force of the patient, which will improve mastication. 

Furthermore, there is strong medical evidence that that the correction of patients with prominent maxillary front teeth like this patient has can reduce the risk of incisor trauma. (4) Orthodontic treatment will reduce her overjet to a more ideal 1-2 mm. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness; Falls
Issue under review: Inpatient admission

Determination:
The denial was upheld.

The patient is an adult male who presented to the emergency ward with the complaint of weakness and falls. 

At presentation, the patient's right lower extremity strength was 2/5. He was admitted for stroke, and MRI showed a lacunar infarct in the right putamen. 

The patient presented with new onset right leg weakness that improved after admission. He was found to have an acute small vessel stroke. The severity of new deficit and the etiology of stroke did not warrant acute admission. The diagnostic studies, monitoring, neurology consult and treatment could have been safely and effectively completed at a lower level of care.